Illinois Application Firearm Form – Fill Out and Use This PDF

APPLICATION FOR FIREARM CONTROL CARD

FOR LICENSEE/LICENSED AGENCIES

INSTRUCTIONS

EXEMPTIONS: A peace officer as defined in the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act is exempt from the requirements relating to the possession of a firearm control card. The employing agency shall remain responsible for any peace officer employed under this exemption.

A person employed as an armed security guard at a nuclear energy, storage, weapons, or development site or facility regulated by the Nuclear Regulatory Commission who has completed the background screening and training mandated by the rules and regulations of the Nuclear Regulatory Commission is exempt from registration for a firearm control card.

1.Please type or print.

2.Applicant must be at least 21 years of age to apply for a firearm control card.

3.Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Com- piled Statutes 100/10-65. The social security number may be provided to the Illinois Department of Public Aid to

identify persons who are more than 30 days delinquent in complying with a child support order, or to the Illinois

Department of Revenue to identify persons who have failed to file a tax return, pay tax, penalty or interest shown in a filed return, or to pay any final assessment or tax penalty or interest, as required by any tax Act administered by the Illinois Department of Revenue, or to other entities for verification of identification.

4.The name shown for the employee or licensee to whom the card will be issued must be as it appears on the per-

manent employee registration card or on the private detective, private security contractor, and/or private alarm contractor license that the applicant possesses. An application for a firearm control card may be completed by a licensed private detective, private security contractor, or private alarm contractor working on their own behalf.

5.Applicant must have a verifiable firearm training number (see item 6 of applicant section) to be eligible for firearm control card. The 40-hour firearm training course must have been completed within 2 years preceding this appli- cation or employee must show proof of requalification within the last year.

6.A $75 processing fee, made payable to the Illinois Department of Financial and Professional Regulation, must accompany this application. There will be a $45 triennial fee required for renewal of this card. All fees are nonre- fundable.

7.The firearm control card shall be retained by the employee for the term of employment. Upon termination of em- ployment, the card shall be returned to the Department by the employer. The firearm control card will expire on date specified on face of the card.

8.Child support statement and state tax statement must be answered.

9. Send application and fee to:	Department of Financial and Professional Regulation
	Attn: Division of Professional Regulation
	320 West Washington Street, 3rd Floor
	Springfield, Illinois 62786

IL486-1314 4/19 (DE)

Packet Updated 4/30/19

			THIS SECTION TO BE COMPLETED BY APPLICANT/LICENSEE
	1.	NAME OF EMPLOYEE/LICENSEE TO WHICH CARD WILL BE ISSUE				2. UNITED STATES SOCIAL SECURITY NUMBER
		(Last, First, Middle Initial)
	3.	E-MAIL ADDRESS (REQUIRED)				4.	INDIVIDUAL LICENSE	NUMBER, IF APPLICABLE (115-, 119-, or 124
							Only use one prefix.)
	5.	PERC		6. FIREARM TRAINING NUMBER		7.	F.O.I. NUMBER (You must attach a legible photocopy of active F.O.I.D.
		129-		230-			card.)
	8.	PERSONAL DATA (See reverse side for assistance in completing this				9. I have been trained on the following weapon(s):
		portion.)					Type:	Last Qualification Date (M/D/Y)
		A. Height:	_________	E. Eye Color: _________			Revolver	_____ / _____ / ________
		B. Weight:	_________	F. Race:	_________
		C. Date of Birth: _________		G. Sex:	_________		Semi-automatic	_____ / _____ / ________
		D. Hair Color:	_________				Shotgun	_____ / _____ / ________
							Rifle	_____ / _____ / ________

10.Have you ever had an Illinois license or registration disciplined based upon a violation of the Illinois Private

Detective, Private Alarm, Private Security, Fingerprint Vendor, and Locksmith Act or administrative rule?	Yes	No
If yes, include a detailed explanation of the nature of the offense and the final disposition of the case.

11.Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in federal court? Please do not give details on minor traffic charges, but do include information relating to Driving While Intoxicated (DWI) charges. If yes, attach a personal statement describing the circumstances of the conviction and certified copies of court records of your conviction including the nature of the offense, date of discharge, and a statement from the probation or parole office. In general, a criminal conviction by

itself does not usually result in denial of licensure.

Yes

No

12.Do you now have any disease or condition that presently limits your ability to perform the essential functions of your profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease or condition? If yes, attach a detailed statement, including an explanation whether or not you are currently under treatment.

	Yes	No
13. Have you ever been dishonorably discharged from the armed services or from a city, country, state of	Yes
federal position? If yes, attach explanation.		No

14.In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant's Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support order. Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to contempt of court.

	Are you more than 30 days delinquent in complying with a child support order?	Yes	No
	(NOTE: If you are not subject to a child support order, answer "no.")

15.In accordance with 20 ILCS 2105-15(g), "The Department shall deny any license application or renewal authorized under any licensing Act administered by the Department to any person who has failed to file a return, or to pay the tax, penalty, or interest shown in a filed return, or to pay any final assessment of tax, penalty, or interest, as required by any tax Act administered by the Illinois Department of Revenue, until such time as the requirement of any such tax Act is satisfied."

Are you delinquent in the filing of state taxes?

Yes

No

Signature of Employee/Licensee:

Date:

THE EMPLOYING AGENCY/LICENSEE MUST COMPLETE PAGE 2

IL486-1314

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Ap for Firearm Control Card for Licensed Agencies - Page 1 of 2

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CARD TERMINATION

Upon termination, for any reason, of the employment of the individual to whom card marked below has been issued, it is the respon- sibility of the licensee-in-charge or security director to return the card to the Department. The card must be returned within 72 hours of such termination.

To return the card, Section I of this form must be completed, the card must be attached to the form and mailed to the Department at the address shown at the top of this form.

If the card cannot be obtained for return to the Department, Section II of this form MUST be completed and submitted to the De- partment within 72 hours of termination of the individual’s employment.

Failure to comply with these requirements is grounds for discipline of the license of the licensee-in-charge for agencies licensed by this Department.

Check the box below that pertains to the card being returned for the employee listed on the form:
		CANINE HANDLER AUTHORIZATION CARD							FIREARM CONTROL CARD
		CANINE TRAINER AUTHORIZATION CARD
SECTION I--PERTAINS TO CARD WHICH HAS BEEN RETURNED (ATTACH CARD TO FORM)
1. EMPLOYEE NAME (Last, First, Middle Initial)							2. SOCIAL SECURITY NUMBER
							___ ___ ___ - ___ ___ - ___ ___ ___ ___
3.							4. DATE OF EMPLOYEE’S TERMINATION
CANINE HANDLER AUTHORIZATION CARD NUMBER 267				-
CANINE TRAINER AUTHORIZATION CARD NUMBER			266	-			___ ___ / ___ ___ / ___ ___ ___ ___
FIREARM CONTROL CARD NUMBER			229	-				Month		Day	Year

I attest that the above-named employee left the employment of this agency or Proprietary Security Force as indicated and I am hereby returning the card marked above issued to said individual.

Signature_____________________________________________		_________________________________________________
	Licensee-in-Charge or Security Director	Name of Agency or Proprietary Security Force
	_____________________________________________	_________________________________________________
	License Number of Licensee-in-Charge	License Number of Agency or Registration Number
	(Not Applicable for Proprietary Security Force)	of Proprietary Security Force
SECTION II--PERTAINS TO CARD WHICH HAS NOT BEEN RETURNED
A.	EMPLOYEE NAME (Last, First, Middle Initial)	B. SOCIAL SECURITY NUMBER
		___ ___ ___ - ___ ___ - ___ ___ ___ ___

C.CANINE HANDLER AUTHORIZATION CARD NUMBER 267 -

CANINE TRAINER AUTHORIZATION CARD NUMBER 266 -
FIREARM CONTROL CARD NUMBER			229 -
D. EMPLOYEE FIREARM OWNER’S I.D. CARD NUMBER (For FCC only)					E.	EXPIRATION DATE OF FIREARM CONTROL CARD
F. DATE EMPLOYEE LEFT AGENCY			G. THE CARD MARKED ABOVE IS NOT ATTACHED FOR THE FOLLOWING REASON(S):
___ ___ / ___ ___ / ___ ___ ___ ___
Month	Day	Year

I attest that the above-named employee left the agency or Proprietary Security Force as shown above.

Signature_____________________________________________	_________________________________________________
Licensee-in-Charge or Security Director	Name of Agency or Proprietary Security Force
_____________________________________________	_________________________________________________
License Number of Licensee-in-Charge	License Number of Agency or Registration Number
(Not Applicable for Proprietary Security Force)	of Proprietary Security Force
IL486-1393 9/16 (DE)