Fill and Sign the Application for Gun Permit 497331137 Form

Application for Gun Permit To: ____________________________ (Title of Law Enforcement Official or Other Authority) County of _____________ State of ________________ I, the undersigned, in accordance with the provisions of _______________________ (citation of state statute) , make application for a __________________ (License or Permit) to carry concealed the following weapon: 1. Description of weapon: [ ] Pistol, [ ] Revolver [ ] Other Weapon): (describe) __________________________________________ ________________________________________________________________ 2. Name of Manufacturer: __________________________________________________ 3. Serial No.: _________________________________________________ 4. Caliber: ____________________________________________________ In support of this application, the following information is hereby submitted: A. Applicant's Name: ________________________________________________ B. Date of Birth of Applicant: ______________________________________ C. Age: _____________________ D. Birthplace of Applicant: _______________________________________ E. Sex: ____________ F. Occupation: _____________________________________________________ G. Present Address: __________________________________________________ H. Former Addresses (last ___ years): ___________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I. Business Address: _________________________________________________ _____________________________ (street number, city, county, state and zip code) J. Marital Status (Married/Single/Divorced): _______________________________ K. Home Telephone Number: __________________________________________ L. Work Telephone Number: __________________________________________ M. Identification ______________________________________________ (driver's license, include state of issue and number) N. Height of Applicant: _____________________ O. Weight of Applicant: ____________________ P. Color of Eyes: ______________________ Q. Color of Hair: ______________________ R. Social Security No. _____________________________________________ S. Reason for desiring a license to carry concealed the above-described weapon: _______________________________________________________________ 1. Have you ever suffered from a mental disorder? [ ] Yes [ ] No 2. Have you ever been confined in a mental institution? [ ] Yes [ ] No If yes, where was it? (Name and Location): _________________________________ ___________________________________________________________________ 3. Have you ever been convicted of an offense other than a traffic violation in this or any other state? [ ] Yes [ ] No If yes, provide details of prior conviction: ____________________________________ ____________________________________________________________________ 4. Are you under indictment in this state for a crime having a penalty in excess of ____ months? [ ] Yes [ ] No If yes, provide details of indictment: ____________________________________ ____________________________________________________________________ 5. Give two character references who (1) are not related to you; (2) are residents of ________________________ (name of county) ; and (3) are at least 21 years old. a. Name: _______________________________________________________ Address: _____________________________________________________ Phone Number: _______________________________________________ b. Name: _______________________________________________________ Address: _____________________________________________________ Phone Number: _______________________________________________ 6. List the Names of any Police Officer or Deputy Sheriff who knows you: a. Name: _______________________________________________________ Agency or Department:__________________________________________ Phone Number: _______________________________________________ b. Name: _______________________________________________________ Agency or Department:__________________________________________ Phone Number: _______________________________________________ I certify that the above information is true and correct. ( Note: False Certification of Information will Result in Refusal or Revocation). Witness my signature this the ___________________ (date) . _____________________________________ (Printed Name of Applicant) _____________________________________ (Signature of Applicant) Information to be Inserted by Board or Officer Issuing License To the Applicant: Your application for a license to carry concealed the above-described weapon is: [ ] Approved [ ] Denied for the following reasons: _________________________________________ ____________________________________________________________________ A license issued under this application expires __________________ (number of months or years) after the date of issuance.  Number of License Issued: ____________________________  Date issued: _______________________________________ Dated: _______________ _______________________________________ (Printed Name of Officer Issuing License) _______________________________________ (Signature of Officer Issuing License)