Fill and Sign the Get and Sign Application for Gun Permit Form Fill Out and

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 [ ] No2. 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 LicenseTo 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)