Dps 799 C PDF Details

The DPS-799-C form plays a critical role in Connecticut's approach to firearm safety and regulation, serving as the foundational document for anyone seeking a permit or eligibility certificate related to pistols, revolvers, or long guns. Administered by the Connecticut Department of Emergency Services and Public Protection, Division of State Police, this comprehensive application encompasses a range of permits, including temporary state pistol permits, non-resident state pistol permits, and eligibility certificates for purchasing pistols, revolvers, or long guns. Applicants are advised to review Connecticut's firearm statutes to understand the requirements and regulations governing firearm ownership, which are available online or at local libraries. In addition to personal and contact information, the form requires detailed employment history, criminal and medical history disclosures, and proof of firearms safety training. Additionally, it outlines the process for submitting fingerprints for a criminal history check—a mandatory step that involves separate fees. The form also includes sections for those with military history and those affected by protective or restraining orders, highlighting the state's thorough vetting process for ensuring the responsible ownership and use of firearms. By doing so, Connecticut aims to balance the rights of individuals to own firearms with the imperative to safeguard public safety.

QuestionAnswer
Form NameDps 799 C
Form Length4 pages
Fillable?Yes
Fillable fields121
Avg. time to fill out25 min 16 sec
Other namesdps 799 c fillable form, form dps 799 c, depss ct 799c form fillable form 2018, ct form dps 46 c

Form Preview Example

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

Special Licensing and Firearms Unit

PISTOL PERMIT/ELIGIBILITY CERTIFICATE APPLICATION

(Pursuant to C.G.S. §§ 29-28 et. seq., 29-36 et. seq., and 53a-217 et. seq.

Before completing this application, it is suggested that you review the Connecticut General Statutes pertaining to firearms. These can be accessed on the Internet at www.cga.ct.gov. or through your local library.

Type of Permit Requested:

Check Box:

60 Day Temporary State Pistol Permit

Non-Resident State Pistol Permit

Eligibility Certificate to Purchase Pistols or Revolvers

Eligibility Certificate to Purchase Long Guns

Instructions:

 

 

 

 

Instructions for Eligibility

 

 

 

Instructions for Non-Resident

Certificates to Purchase Pistols

Instructions for State Pistol Permits:

 

State Pistol Permits:

or Revolvers and/or Eligibility

 

 

 

 

Certificates to Purchase Long

 

 

 

 

Guns:

1. Complete this form (DPS-799-C) and submit to

 

**CALL DESPP FOR PACKET**

1. Complete this form and submit in

appropriate local authority (local police, resident

You must hold a valid permit or

person at DESPP Headquarters,

state trooper or first select person, as applicable)

license to carry a pistol or revolver

Division of State Police, located at

along with all of the following:

issued by a recognized United States

1111 Country Club Road,

Firearms Safety & Use Course Certificate;

jurisdiction.

Middletown, Connecticut along with

 

 

the below:

$70.00, fee, payable to the local authority;

Complete this form and submit to

 

and

DESPP, Division of State Police, pistol

Firearms Safety & Use Course

Proof you are legally and lawfully in the

permit location along with all of the

Certificate;

 

United States (e.g., certified copy of birth

following:

$35.00 fee, payable to

 

certificate, U.S. passport or documentation

Completed State of CT and Federal

Treasurer, State of

 

issued by I.C.E.).

Connecticut;

 

 

fingerprint card with $75.00 fee and

 

 

 

Application for a State Eligibility

2. Submit fingerprints for a criminal history check

 

$13.25 fee, payable to Treasurer,

 

Certificate for a Pistol or

through a law enforcement agency. Fees include

 

State of Connecticut for criminal

 

Revolver or for Long Guns

a $75.00 fee and a $13.25 fee, payable at the

 

history background checks;

 

(DPS-164-C);

agency where the prints are taken. Fees must be

Firearms Safety & Use Course

Proof you are legally and

paid by separate checks.

 

Certificate;

 

lawfully in the United States

 

 

$70.00 fee, payable to Treasurer,

3. Upon approval, the local authority will issue a

(e.g., certified copy of birth

 

State of Connecticut;

Temporary State Permit to Carry Pistols and

 

certificate, U.S. passport or

Completed Application for State

Revolvers (DPS-11-C), effective for 60 days.

documentation issued by

 

Permit to Carry Pistols and Revolvers

 

 

 

I.C.E.); and

4. Within the 60 day period, go to a DESPP,

 

form (DPS-46-C);

Proof of valid state issued photo

Division of State Police, pistol permit location and

Completed DPS-129-C signed and

identification card.

submit the following:

 

notarized and 2x2 color photograph

 

 

The Temporary State Permit to Carry Pistols

(passport style);

2. Submit fingerprints for a criminal

Copy of the permit or license to carry

history check through a law

 

and Revolvers (DPS-11-C) issued by the

 

 

a pistol or revolver issued to you by a

enforcement agency. Fees include a

 

local authority;

 

 

 

recognized United States jurisdiction;

$75.00 fee and a $13.25 fee, payable

A completed Application for State Permit to

Proof you are legally and lawfully in

at the agency where the prints are

 

Carry Pistols and Revolvers (DPS-46-C);

 

 

the United States (e.g., certified copy

taken. Fees must be paid by separate

$70.00 fee, payable to Treasurer, State of

 

 

of birth certificate, U.S. passport or

checks.

 

Connecticut;

 

 

 

documentation issued by I.C.E.);and

 

Proof you are legally and lawfully in the

 

3. Upon approval, your photograph will

Proof of valid state issued photo

 

United States (e.g., certified copy of birth

 

identification card.

be taken at DESPP and you will be

 

certificate, U.S. passport or documentation

 

issued an eligibility certificate.

 

Out of State Pistol Permit Information:

 

issued by I.C.E.); and

 

Proof of valid state issued photo identification

State of Issue: _______________

 

 

card.

 

 

 

5. Upon approval, your photograph will be taken at

Expiration Date: _____________

 

 

 

 

DESPP and you will be issued a state pistol permit.

Permit Number: ______________

 

For Department of Emergency Services and Public Protection (DESPP), Division of State Police, pistol permit locations, access www.ct.gov/despp and follow the link to the Special Licensing and Firearms Unit or call (860) 685-8290. Note: All payments must be made with separate checks.

DPS-799-C (Rev. 12/28/18)

An Affirmative Action/Equal Employment Opportunity Employer

Page 1 of 4

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

Contact / Identifying Information:

 

Name of Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Middle Initial

 

 

 

 

Provide all other names by which you have been known (Maiden name, Aliases, Nicknames, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Attach additional sheet(s), if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex

 

 

 

 

 

 

 

 

Height

 

 

 

 

 

 

 

 

 

 

 

Weight

 

 

 

 

 

 

Eye Color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

M

 

 

 

 

 

Ft.

 

 

 

In.

 

 

 

 

 

 

 

 

 

Lbs.

 

 

 

Brown

 

Blue

Black

 

 

 

 

Month/Day/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Green

 

Gray

Hazel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hair Color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

American Indian/Alaskan Native

 

 

 

Asian/Pacific Islander

 

 

 

 

 

 

 

 

Brown

 

Black

Blonde

Red

 

Black

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

Gray

 

White

Bald

 

 

 

 

Place of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number (Optional, but will help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

prevent misidentification)

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Country of Citizenship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alien Reg. Number (If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential Address (List street address. Post office box numbers are not acceptable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number/Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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-

 

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Residential Addresses for the Last 7 Years

 

 

(Attach additional sheet(s), if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Any subsequent changes of address must be reported within 48 hours

 

to the Special Licensing and Firearms Unit

 

 

 

1. ___________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

2. ___________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

Mailing Address (If different from current residential address above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number/Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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-

 

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone Number

 

Motor Vehicle Operator’s License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Area Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State of Issue

 

 

 

 

Alternate Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment History:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List Employers for the Last 7 Years (Provide employer’s name, address and telephone number)

 

 

 

 

 

 

 

 

 

 

(Attach additional sheet(s), if necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. __________________________________________________________________________________

 

 

 

 

 

 

 

 

 

2. ___________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permit or Eligibility Certificate

History:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you had a firearms permit, permit application or eligibility certificate of any kind from ANY jurisdiction in the United States denied, suspended or revoked? NO YES

If "YES,” provide:

1.Identify the jurisdiction which issued the denial, suspension or revocation: ___________________

2.Date of denial, suspension or revocation: _______________________________________________

3.The reason for the denial, suspension or revocation:______________________________________

DPS-799-C (Rev. 12/28/18)

An Affirmative Action/Equal Employment Opportunity Employer

Page 2 of 4

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

Medical History:

Have you been confined in a hospital for mental illness in the past sixty (60) months by order of a Probate Court?

NO

YES If "YES," explain: (Attach additional sheet(s), if necessary)

Have you been discharged from custody within the past twenty years after having been found not guilty of a crime

by reason of a mental disease or defect?

NO YES

If "YES," explain: (Attach additional sheet(s), if necessary)

Have you been voluntarily admitted to a hospital for mental illness within the past six (6) months for reasons other than solely for alcohol or drug dependence? NO YES

If "YES," explain: (Attach additional sheet(s), if necessary)

Notice: DESPP herein notifies the applicant that, pursuant to C.G.S. §§ 29-28 through 29-38b, DESPP will be notified by the Department of Mental Health and Addiction Services if the applicant has been confined to a hospital for psychiatric disabilities within the preceding sixty (60) months by order of Probate Court, or if the applicant has been voluntarily admitted to a hospital for mental illness within the past six (6) months for reasons other than solely for alcohol or drug dependence.

Criminal History:

Have you ever been ARRESTED for any crime, in any jurisdiction? NO YES If "YES," list all arrests, indicating charges, locations, dates of arrest and dispositions. (Attach additional sheet(s), if necessary)

Notice: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to C.G.S. §§46b-146, 54-76o, or 54-142a. If your criminal records have been erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records that may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. 46b-146), an adjudication as a youthful offender (C.G.S. 54-76o), a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, or a conviction for which the person received an absolute pardon (C.G.S. 54-142a).

With regard to criminal history information arising from jurisdictions other than the State of Connecticut: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to the law of the other jurisdiction. Additionally, you are not required to disclose the existence of an arrest arising from another jurisdiction if you are permitted under the law of that jurisdiction to swear under oath that you have never been arrested.

Have you ever been CONVICTED under the laws of this state, federal law or the laws of another jurisdiction?

NO YES If "YES,” list all convictions, include charges, location, date of arrest, and disposition. (Attach additional sheet(s), if necessary)

Are you currently on probation, parole, work release, in an alcohol and/or drug treatment program or other pre-trial diversionary program or currently released on personal recognizance, a written promise to appear or a bail bond for

a pending court case?

NO

YES If "YES," explain. (Attach additional sheet(s), if necessary)

Within the

past five (5) years, have you been the subject of a Protective Order or Restraining Order issued by a

court in a

case involving the use, attempted use or threatened use of physical force against another person,

regardless of the outcome or result of any related criminal case?

NO

YES

If “YES,” which court issued the order?

Military History:

Were you ever a member of the Armed Forces of the United States?

NO YES (If yes, please include a copy of your DD-214)

Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge?

NO

YES

DPS-799-C (Rev. 12/28/18)

An Affirmative Action/Equal Employment Opportunity Employer

Page 3 of 4

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

Proof of Training:

*Attach a copy of the letter or certificate attesting that you have completed a course in the safety and use of pistols and revolvers or long guns (as appropriate, depending upon which permit or certificate you are requesting), signed by the instructor of the course.

Instructor: (Check applicable box)

National Rifle Association

Department of Energy and Environmental Protection (DEEP)

Other: ___________________________________

State Instructor's Name and ID Number:_______________________________________________________

Declaration:

I understand that any false statement herein, which I do not believe to be true and which is intended to mislead a public servant in the performance of his or her official function, is punishable by law (See CGS § 53a-157b). I further understand that any statement in this application that is determined to be false or inaccurate shall constitute grounds for the denial of such application. If approved before the facts are known, such approval shall be void if based on a false or inaccurate statement. My signature below attests to the accuracy, completeness and to the truth of all information supplied on this application:

I declare, under the penalties of false statement, that the answers to the above are true and correct.

Date ____________________

Signed

 

 

 

STATE OF

 

 

 

 

 

 

 

 

Print Name

 

 

 

COUNTY OF _______________

 

 

 

 

 

 

Subscribed and sworn to before me this ______ day of

 

 

20_____

Name:

Notary Public

My Commission Expires:

Commissioner of Superior Court

NOTICE: Appeal Process for Permits

In the event that your application for pistol permit or eligibility certificate is denied or revoked, you may notify the Board of Firearm Permit Examiners, at 20 Trinity St., 5th Floor, Hartford, CT 06106. Telephone: (860)256-2977 OR (860) 256-2947, in writing, within ninety (90) days, in order to begin your appeal process. At a hearing before the Board, you may request that your application be reconsidered or that your permit or eligibility certificate be reinstated.

For Official Use Only:

Application Received:

 

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/

 

Month/Day/Year

FBI Sent:

FBI Reply:

ICE Response:

DMHAS:

SPBI:

Number :

No Yes

No Yes

No Yes

No Yes

No Yes

Application Status:

Approved Denied

(Signature and title of issuing authority)

DPS-799-C (Rev. 12/28/18)

An Affirmative Action/Equal Employment Opportunity Employer

Page 4 of 4

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