Fill and Sign the Application to Carry a Concealed Weapon Pistol Revolver or Other Firearm Form

Application to Carry a Concealed Pistol, Revolver or other Firearm 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. Occupation: _____________________________________________________ C. Residence Address: ________________________________________________ ____________________________ (street number, city, county, state and zip code) D. Business Address: _________________________________________________ _____________________________ (street number, city, county, state and zip code) E. Age: ________ F. Date of birth (month/day/year): ______________________________ H. Identification: _____________________________________ (driver's license, include state of issue and number) I. Height of Applicant: _____________________ J. Weight of Applicant: ____________________ K. Color of Eyes: ______________________ L. Color of Hair: ______________________ M. Reason for desiring a license to carry concealed the above-described weapon: _______________________________________________________________ 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)