Dps 799 C – Fill Out and Use This PDF

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.

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

Contact / Identifying Information:

Name of Applicant

,

.

Last

Suffix

.

First

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

State

-

-

Country of Citizenship

Alien Reg. Number (If applicable)

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

Number/Street

,

-

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

,

-

City/Town

State

Zip Code

Home Telephone Number

Motor Vehicle Operator’s License Number

(

)

-

Area Code

State of Issue

Alternate Telephone Number

(

)

-

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:______________________________________

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:

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: