Have you ever been volunatyily or involuntarily committed to a treatment facility for the abuse of a controlled substance

Transcript

1 CONCEALED HANDGUN CARRY LICENSE APPLICATION FORM DEPARTMENT OF ARKANSAS STATE POLICE ) (Please print clearly and provide all requested information NON -REFUNDABLE *** *** NOTICE: THE APPLICATION FEE IS Your application may be denied based on the information you provide. Please read the law and the Administrative Rules carefully. If you have questions about your eligibility, please consult your instructor. New Application Renewal Application Transfer Application Check one: Full Name: ____________________________________________________________________________ First Middle Jr., Sr., or III (if applicable) Last For RENEWAL or TRANSFER only: Cu rrent Concealed Handgun Carry License #: __ _________________ Exp iration date: ______ _________ Give all other names you have ever used: ______________________________________________ Date of Birth: ____________________ Place of Birth: ________________ Race: _____ Sex: _____ (Mon th/Day/Year) (City) (State) Social Security #: ___________________Driver’s License #: ______________________ ________ State Hair color: ________________ Eye color: ______________ Height: _______ feet _______ inches Physical Address: _____________________________________________________________________ _______________________________________________________________________________________ City State ZIP Mailing Address: ______________________________________________________________________ _______________________________________________________________________________________ State City ZIP List the county of your physical residence: _____________________________________________ Do you live within the city limits? _____________ I f yes, what ci ty? _______________________ Please supply contact information so we may reach you if we have questions or problems . with your application packet. Please print clearly Home phone number: ______________________ Daytime phone number: __________________ Cell phone number: ______________________ E-mail address: _____________________________ If no, list your Have you lived at this address for the previous two (2) years? ____________ previous addresses for the past two (2) years: _______________________________________________________________________________________ Address City State Zip _______________________________________________________________________________________ Zip Address City State If you must explain an answer to a question, please do so on a separate piece of paper. 1 Revised February 14, 2019

2 QUESTIONS RELATING TO MENTAL HEALTH Have you ever been adjudicated as a mental defective or mentally incompetent? 1. If yes, explain further on a separate piece of paper giving ______________________________ details of the proceedings or providing court documentation. Have you ever been voluntarily committed (overnight stay) to a mental institution or 2. _________________ If yes, please provide the name of the mental health treatment facility? facility, its address, city and state on a separate piece of paper. 3 . Have you ever been involuntarily committed (overnight stay) to a mental institution or mental health _________________ If yes, please provide the name of treatment facility? the facility, its address, city and state on a separate piece of paper. 4. Do you suffer from a mental or physical infirmity that prevents the safe handling of a handgun? ___________________ 5. Have you ever threatened or attempted suicide? ______________________ QUESTIONS RELATED TO THE USE OF CONTROLLED SUBSTANCES 6. In the last three (3) years, have you been voluntarily or involuntarily committed (overnight stay) to a treatment facility for the abuse of a controlled substance? _______________________ If yes, please provide the name of the facility, its address, city and state on a separate piece of paper. 7. Have you ever been convicted of a crime relating to a controlled substance? _________ If yes, what was the date of that conviction? _____________________ 8. Do you chronically or habitually abuse a controlled substance to the extent that your normal faculties are impaired? (This includes any discharge from the military for drug usage.) ____________________________________________ 9. Are you currently an unlawful user of any controlled substance? ___________________ If yes, list the last date that you used the controlled substance. ________________________ QUE STIONS RELATED TO THE USE OF ALCOHOL Do you chronically and habitually use any 10. alcoholic beverage to the extent that your normal faculties are impaired? ___________________________________________________ In the last three (3) years, have you ever been voluntarily or involuntarily 11. committed (overnight stay) to an alcohol abuse treatment facility? _______________ If yes, give name and address of the treatment facility and discharge date. ___________________ ______________________________________________________________________________________ 12. Within the three (3) years immediately preceding this application, have you been convicted of two (2) or more offenses related to the use of alcohol? _____________________ If yes, explain further on a separate piece of paper. In the last five years, have you been found guilty of an alcohol related offense while 13. you were carrying a handgun? _______________ If yes, explain further on a separate piece of paper. 2 Revised February 14, 2019

3 QUESTIONS RELATED TO OTHER CRIMINA L HISTORY Have you been convicted of a crime(s) that involves 14. contact or threat of physical physical contact with a family member, intimate partner, your child or a child of the intimate partner? _________________ If yes, explain further on a separate piece of paper Have you been convicted of a crime of violence? ________________________ If yes, 15. explain further on a separate piece of paper. 16. Have you been convicted of any crime involving the of a weapon? ______________ use 17. Have you ever been convicted of a felony? _________________ NOTE – if you were sentenced after March 13, 1995, you must have a governor’s pardon with firearms possession rights restored. A seal/expungement order will not necessarily restore your firearms rights. 18. Within the last five (5) years have you ever been convicted of the offense of carrying a weapon? ________________ If yes, give the court and date of conviction. _______________ _______________________________________________________________________________________ 19. Are you the subject of an active criminal warrant? Yes No Unknown (Circle one) FEDERAL LAW QUESTIONS RELATING TO 20. in any state? Have you ever been denied a concealed handgun carry license ___________________ If yes, what state? ________________________ 21. Have you ever been denied for the purchase of a firearm through a federal firearms licensee (gun dealer)? ______________ If yes, explain further on a separate piece of paper. 22. Have you ever been convicted in any court of a crime punishable by imprisonment for a term exceeding one (1) year? _______________ If yes, please explain further on a separate piece of paper. 23. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance? WARNING: of use or possession The marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in the state where you reside. _____________ If yes, please explain further on a separate piece of paper. 24. Do you currently possess a medical marijuana registry identification card, including a qualified patient card? ______________ If yes, please provide a copy of the card. 25. Have you possessed a medical marijuana registry identification card, including a qualified in the past year? ________________ If yes, please explain further on patient card a separate piece of paper. 26. Have you recently been arrested for or are you under indictment or information for a crime punishable by imprisonment for a term exceeding one year? _________________ If yes, explain further on a separate piece of paper. Have under dishonorable you ever served in the Armed Forces and been discharged 27. conditions? ___________________ (dishonorable discharge or dismissal) 3 Revised February 14, 2019

4 28. Have you ever been convicted of an offense at an Armed Forces General Court Martial? __________________ If so, what was the offense? _______________________________ 29. Are you a fugitive from justice? ______________________ 30. Are you subject to any law that makes it unlawful to receive, possess or transport any firearm? _________________ 31. Have you ever submitted information to the FBI for the Voluntary Appeal File (VAF)? If yes, was a VAF number issued to you? _________ If yes, list that number: _____________ 32. Are you an illegal or unlawful alien? ________________________ Are you the subject of a court order, such as a restraining or protection order, that 33. restrains you from harassing, stalking or threatening your child, intimate partner or child of the intimate partner? ___________ If yes, please provide a copy of the court order. 34. Have you ever renounced your United States Citizenship? ___________________ QUESTIONS RELATING TO ARKANSAS LAW 35. Are you a citizen of the United States? _________________ a. If yes , do you declare allegiance to the United States Constitution and the Arkansas Constitution? _________________ , are you a permanent legal resident of the United States? _____________ If yes, b . If no please attach proof of your current status. If you were born outside please send a copy of your United States Passport; United the United States of States birth certificate; US citizen born abroad certificate; OR Permanent resident card issued by the United States. Have you been a resident of Arkansas continuously for at least ninety (90) days prior 36. to the signing of this application (does not apply to transfers)? _________________ 37 . Have you bee n furnished with a copy of ACA §§5-73 -301 et seq. (the Arkansas concealed handgun carry licensing law) and are you acquainted with the truth and understanding of this subchapter (does not apply to transfers)? _____________ 38. Are you at least twenty-one (21) years of age at the time of signing this application? ____________ If no, are you at least eighteen (18) years of age and a current or former active duty member of the United States military? _______________ Please provide proof of active duty military status. 39. Do you desire a legal means to carry a concealed handgun to defend yourself?______ unrestricted license 40. Are you applying for an (live-fire qualification was done with a or restricted license (live-fire qualification was done with a semi-automatic handgun) revolver)? ____________________________________ 4 Revised February 14, 2019

5 NOTICE: THE APPLICATION FEE IS NON -REFUNDABLE *** *** Your application may be denied based on the information you provide. Please read the law and the Administrative Rules carefully. If you have questions about your eligibility, please consult your instructor. I understand that if any information or answer to a question on this application changes during the licensing period that I will immediately notify the Department in writing. I hereby state that all information on this application is correct. I understand that knowingly giving a false statement or submitting a false document will subject me to criminal prosecution, uance, and/or result in immediate revocation preclude future concealed handgun carry license iss of any license already issued by the Department . I give my consent to the Arkansas State Police to conduct a thorough investigation into my qualifications to be licensed to carry a concealed handgun. I release any records or reports held by any physician, medical professional, medical facility, mental institution, state or federal agency , court or law enforcement agency and authorize all such entities to furnish detailed information from their records as it rela tes to my to achieve application. I agree to sign any additional releases as may be required by any entity this purpose. A copy of this authorization shall serve in the place of and the same as the original. o long as I hold or attempt to hold an Arkansas This release is continuing in force and effect s concealed handgun carry license. I understand that my fingerprints that I submit will be used to check the criminal history records of the FBI and that I may challenge the completeness or nal history information by using the procedures as outlined in Title 28, Code accuracy of my crimi of Federal Regulation (CFR) Section 16.34 and/or Arkansas Code §12 -12 -1013. The procedures for obtaining a copy of the FBI criminal history record are set forth in Title 28, Cod e of Federal Regulations (CFR), Section 16.30 through 16.33 or go to the FBI website at http://www.fbi.gov/about -us/cjis/background -checks . The procedures for obtaining a change, or updating of an FBI criminal history record are set forth in Title 28, Code of Federal correction Regulations (CFR), Section 16.34. Signature: _________________________________________________ Date: ____________________ (Month/Day/Year) (First/MI/Last Name) . 5 Revised February 14, 2019

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