Wp5 Form – Fill Out and Use This PDF

IOWA APPLICATION FOR PERMIT TO CARRY WEAPONS

[For a permit to be issued on or after January 1, 2011]

INFORMATION PROVIDED ON THIS FORM IS PUBLIC RECORD

New Application

Renewal Application – Permit Number ___________________ Permit Expiration Date ________________

Renewal applications must be received by the issuing officer at least thirty days prior to the expiration of the applicant’s current permit

Type of Permit:
Professional Permit (WP1)	Peace Officer Permit (WP7)
Nonprofessional Permit (WP2)	Reserve Peace Officer Permit (WP10)
Training Documentation:
Photocopy of certificate of handgun training	Honorable/general discharge or DD-214
Affidavit attesting to completion of handgun training	Certificate of completion of military basic training

Qualified on a firing range under the supervision of a certified instructor (applies to renewal application only)

Name ___________________________________________________ Alias(s) ___________________________

(last)(first)(middle)(other names ever used)

Birthdate ____ /____ /_______ Sex		M F	Phone (____)______-________ Phone (____)______-_________
MM	DD YYYY	Circle

Residence __________________________________________________________________________________

(city)(state) (zip)

Driver’s License or Non-Operator ID#________________________ Driver’s License/ID State ________________

Place of Birth (state or country) _________________________ Country of Citizenship _________________________

If not US citizen, alien registration # (ARN) or I-94 nonimmigrant admission # _____________________________

Authorization for Release – Weapon Permit Applications

I, (print name here) _____________________________________________, do hereby authorize a review and full disclosure

of all records concerning myself, as required by Iowa Code Ch. 724 and Iowa Administrative Code 661—Ch 91, to any duly authorized agent of an Iowa sheriff or the Commissioner of the Iowa Department of Public Safety, whether the said records are of a public, private or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of records of psychiatric treatment, substance abuse treatment, consultation and/or court ordered involuntary committal for treatment including those records held by hospitals, clinics, private practitioners, the U.S. Veteran’s Administration and clerks of court, as necessary to verify that I meet the requirements of the state of Iowa and the United States for the acquisition and possession of a firearm. I understand that the information contained in these records will be used for no purpose other than those stated above, and will be kept strictly confidential by the office of the issuing official.

I understand that any information obtained which is developed directly or indirectly, in whole or part, upon this release authorization will be considered in determining my qualification for obtaining a permit to carry weapons in the state of Iowa. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for providing accurate information, and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.

I understand that information provided on this application form is considered public record and may be disclosed upon request.

I certify that all information, including supporting documentation, provided in this application is true and correct, and I understand that I may be convicted of a class “D” felony pursuant to Iowa Code section 724.10(3) if I make what I know to be a false statement of material fact on this application or if I submit what I know to be any materially falsified or forged documentation in connection with this application.

Applicant Signature ______________________________________________

Date ____________________

Answer all questions on reverse side and complete employer authorization section (if applicable)

WP5 Rev. 2011.1 10/29/2010

All of the following questions must be answered:

Yes No

1.Do you have charges pending in any state for a felony, or any other crime for which the court could sentence you to imprisonment for more than one year?

2.Have you ever been convicted in any court of a felony, or any other crime involving a firearm or explosives for which the court could have sentenced you to imprisonment for more than one year, even if you received a shorter sentence including probation?

3.Have you been convicted in any court within the previous three years of a serious or aggravated misdemeanor defined in Iowa Code Ch. 708 not involving a firearm or explosives for which the court could have imprisoned you for more than one year, even if you received a shorter sentence including probation?

4.Are you a fugitive from justice (outstanding arrest warrants)?

5.Are you an unlawful user of, or addicted to, any controlled substance?

6.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 to others or are incompetent to manage your own affairs) OR have you ever been committed to a mental institution?

7.Have you been discharged from the Armed Forces under dishonorable conditions?

8.Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an intimate partner or child of such partner?

9.Have you ever been convicted in any court of a misdemeanor crime of domestic violence?

10.Are you a citizen of the United States? (IF NO, immigrant must provide alien registration number (ARN); nonimmigrant must provide I-94 registration number and documentation showing an exception to the nonimmigrant alien prohibition (e.g., valid hunting license issued in any state, letter from the U.S. Attorney General granting a waiver, etc.).

11.Have you ever renounced your United States citizenship?

EMPLOYER AUTHORIZATION (required for Professional Permit only)

Employer Name _____________________________________________ Telephone ______________________

Employer Address ____________________________________________________________________________

Employment Justification ______________________________________________________________________

__________________________________________________________________________________________

Employer Signature _____________________________________________ Date ________________________

ISSUING OFFICER (Iowa Sheriff or Commissioner of Public Safety)

Application: Approved DeniedDate _________________________________

Reason Denied: _______________________________________________________________________________________________

________________________________________________________________________________________________________________

Written Denial Notice Provided By (method) ______________________________ on (date) ________________

	Sheriff of __________________________ County, Iowa
Signature ________________________________	Commissioner of the Iowa Department of Public Safety