Application Carry Concealed Form – Fill Out and Use This PDF

SECTION III, continued

(8) Have you ever been convicted of, or pleaded guilty to, a misdemeanor offense of violence, charge
of domestic violence, or a similar offense, in this or any other state?	YES	NO

(9)Are you under indictment for, or otherwise charged with, or, except for a conviction or guilty plea the records of which a court has ordered sealed or expunged or relative to which a court has granted relief from disability pursuant to ORC 2923.14, have you been convicted of or pleaded guilty to, within three years of the date of this application, except for a conviction or guilty plea the records of which a court has ordered sealed or expunged or relative to which a court has granted relief from disability pursuant to ORC 2923.14, a misdemeanor that is an offense of violence or the offense of possessing a revoked or suspended concealed handgun license, or, except for a conviction or guilty plea the records of which a court has ordered sealed or expunged or relative to which a court has granted relief from disability pursuant to ORC 2923.14, have you been adjudicated as a delinquent child within

three years of the date of this application for committing an act that would be a misdemeanor of
that nature, if committed by an adult?	YES	NO

(10)Are you under indictment for or otherwise charged with, or, except for a conviction or guilty plea the records of which a court has ordered sealed or expunged or relative to which a court has granted relief from disability pursuant to ORC 2923.14, or have you been convicted of or pleaded guilty to, within 10 years of the date of this application, resisting arrest, or, except for a conviction or guilty plea

the records of which a court has ordered sealed or expunged or relative to which a court has granted
relief from disability pursuant to ORC 2923.14, have you been adjudicated as a delinquent child for
committing, within 10 years of the date of this application, an act that if committed by an adult
would be the offense of resisting arrest?	YES	NO

(11)(a) Are you under indictment for, or otherwise charged with, assault or negligent assault?

(b)Have you been convicted of, pleaded guilty to, or adjudicated as a delinquent child two or more times for committing assault or negligent assault within five years of the date of this application?

(c)Except for a conviction, guilty plea, or delinquent child adjudication the records of which a court has ordered sealed or expunged or relative to which a court has granted relief from disability pursuant to ORC 2923.14, have you ever been convicted of, pleaded guilty to, or adjudicated as a

	delinquent child for assaulting a peace officer?	YES	NO
(12)	(a) Have you ever been adjudicated as mentally incompetent or mentally defective?	YES	NO
	(b) Have you ever been committed to a mental institution?	YES	NO
	(c) Have you ever been involuntarily committed to a mental hospital or facility for purposes other
	than observation?	YES	NO
	(d) Have you ever been adjudicated as mentally defective (which includes having been adjudicated as
	incompetent to manage your own affairs, or ever been committed to a mental institution?	YES	NO
(13)	Are you currently the subject of a civil protection order, a temporary protection order,
	or a protection order issued by a court of this or any other state?	YES	NO

(14)Are you currently subject to a suspension imposed under ORC 2923.128(A)(2) of a license to carry a concealed handgun or a temporary emergency license to carry a concealed handgun that previously

was issued to you, or are you subject to a similar suspension by another state?

YES

NO

(15)Are you a member of the United States Military on permanent change of station (PCS) orders

to Ohio? YES NO

(16)Are you a permanent resident of Ohio on permanent change of station (PCS) orders to a military assignment

outside of Ohio? YES NO

(17) Are you a resident of another state?			YES	NO
State of residence		If a resident of another state, are you employed in Ohio?	YES	NO

SECTION IV

THESE QUESTIONS ARE REQUIRED TO DETERMINE IF YOU CAN PASS THE NATIONAL INSTANT CRIMINAL BACKGROUND CHECK SYSTEM AND RECEIVE AN OHIO CONCEALED HANDGUN LICENSE:

(1) Are you under indictment or information in any court for a felony, or any other crime, for which
the judge could imprison you for more than one year?	YES	NO

(2)Have you ever been convicted in any court of a felony, or any other crime, for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence,

	including probation?	YES	NO
(3)	Are you a fugitive from justice?	YES	NO
(4)	Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic
	drug, or any other controlled substance as defined in 21 U.S.C. 802?	YES	NO

(5)Have you ever been adjudicated mentally defective (which includes a determination by a court, board, commission, or other lawful authority that you are a danger to yourself or others or are incompetent to manage your own affairs) or have you ever been committed to

	a mental institution?	YES	NO
(6)	Have you ever been discharged from the Armed Forces under dishonorable conditions?	YES	NO
(7)	Are you subject to a court order restraining you from harassing, stalking, or threatening your
	child or an intimate partner of a child?	YES	NO
(8)	Have you ever been convicted of, pleaded guilty to, or adjudicated a delinquent child in any
	court of a misdemeanor crime of domestic violence?	YES	NO
(9)	Have you ever renounced your United States citizenship?	YES	NO
(10) Are you an alien illegally in the United States?		YES	NO
(11) Are you an alien admitted to the United States under a nonimmigrant visa?		YES	NO

(12)If you are an alien admitted to the United States under a nonimmigrant visa, do you fall within any of the exceptions set forth in the instructions to question 12 on the ATF Form 4473? (If you

meet any of these exceptions, you must provide supporting documentation)?

YES

NO

(13)What is your state of residence (if any)?

(14)What is your country of citizenship?

(15)If you are not a citizen of the United States, what is your U.S.- issued alien number or admission number?