Change Of Addresd In Multnomah County Form – Fill Out and Use This PDF

d	Multnomah County Sheriff’s Office	DANIEL STATON
	12240 NE Glisan St., • Portland, OR 97230	SHERIFF
	Exemplary service for a safe, livable community	503 251-2417	PHONE
		503 251-2513	FAX

www.mcso.us

APPLICATION FOR LICENSE TO CARRY CONCEALED HANDGUNS

All processes require payment at time of service. Please DO NOT mail payment with your application (exception—Address change)

	Official Use only		Second ID Type:				US Citizenship:				US Passport

Cert of Naturalization

Competency Instructor

NRA/DPSST #

Birth Certificate

CHL #

(Only if this is a Renewal or Reinstatement)

Exp. Date

Full Legal Name:

Last Name

First Name

Middle Name

Maiden Name and/or Aliases (List all names previously used):

Date of Birth:State of Birth: OR Country if not born in US: Social Security Number:

Disclosure of your social security number is voluntary. Solicitation of the number is authorized under ORS 166.420. It will be used only for identification.

Race

Sex

Height

Weight

Eyes

Hair

Driver’s License #:

State:

Expiration:

Residence Address:

Street Address

City

State

Zip Code

Mailing Address (if different):

Street Address

City

State

Zip Code

Email Address:

List all states where you have lived (since age 18):

Page 1 of 2

Rev 10/2014

Character References (New & Transfer applications only): List 2 local and non-family references:

1.

Name, Complete Mailing Address, and Phone Number are required

2.

Name, Complete Mailing Address, and Phone Number are required

Employer Name, Address, & Phone (Optional):

List residence addresses for the past three years and dates you resided at each (If different from current address):

•

•

INITIAL each line. I hereby declare as follows:

I am a citizen of the United States. If I am not a citizen, I am a legal resident alien who can document continuous residency in Multnomah County or Washington State for at least six months and have declared in writing to the United States Citizenship and Immigration Services my intention to become a citizen and can present proof of the written declaration to the Sheriff at the time of this application.

I am now at least 21 years of age.

I have not been under the jurisdiction of the juvenile department for the last four years for committing an act, that if committed by an adult, would constitute a felony or a misdemeanor involving violence.

I have NEVER been convicted of or found guilty of a felony.

I have NOT, within the last four years, been convicted of or found guilty of a misdemeanor.

There are no outstanding warrants for my arrest.

I do NOT have any charges pending in any court resulting from any citation or arrest.

I have not been mentally committed by a court nor have I been found mentally ill and am not presently subject to an order prohibiting me from purchasing a firearm because of mental illness.

I have never been convicted of an offense involving controlled substance or participated in a court-supervised drug diversion program.

I am not subject to a citation or court order restraining me from contacting or stalking another.

I have not received a dishonorable discharge (enlisted members) or a dismissal (commissioned officers) from the U.S. Armed Forces.

I am not required to register as a sex offender in any state.

I understand I will be photographed and fingerprinted.

I am a Washington State resident and I have a compelling reason for wanting a Concealed Handgun permit in Oregon. (Residents of Multnomah County—please skip this statement or write N/A)

Brief Explanation of Reason:

I have read the entire text of this application and understand it completely. The statements I have made are correct and true. I understand that making false statements on this application is a CRIME. If I have made false statements in this application, I am subject to prosecution and my application will automatically be denied or revoked.

Signature of Applicant:

Date:

Page 2 of 2

Rev 10/2014