STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION DIVISION OF STATE POLICE, Speclal Licensing and Firearms Un PISTOL PERMIT/ELIGIBILITY CERTIFICATE APPLICATION « Before completing his aipicalion, WTS suggasted that you review the Conneclicul General Slaluies pertaining to firearms. These can be accessed on the Interne! at wwwv.cga.ct gov. For those without Inlemet access, please contact your local library. ‘ar Department of Emergency Sorvices and Public Protection (DESPP), Division of Stato Police, pistol permit tocations, access swww.ct.govidespp and folow the link othe Special Licensing and Firearms Unit or call (860) 685-8290. Eligiilly Certiicales must be submitied in porson al DESPP Headquarters [ocaied at 1111 County Club Road, Midiletown, Connecticut. ‘Check Box: 160 Day Temporary State Pistol Permit Non-Resident State Pistol Permit 1 Etiaibity Certificate to Purchase Pistols or Revolvers ‘SEE APPENDIX A (DESPP-788-C) FOR MAGAZINE DECLARATION. ADDITIONAL COPIES CAN BE OBTAINED t www. i Eiigibity Certticate to Purchase Long Guns Instructions: Instructions Cortticatos to Purchase Pistols or Revolvers and/or Eligibility Certificates to Purchase Long Guns: Instructions for Non-Resident State Pistol Pormits: (Contact DESPP for packot) Instructions for 60 Day Temporary State Pistol Permits: 1. Complete this form (DPS-789-C) and submit to ‘appropriate local authoriy (local police, resident slate tooper or first seleciperson, as You must hold a valid permit or licanse to carry a pistol or revolver Complete this form and submit at DESPP Headquarters, Division of State Police, along withthe bolow: issued by a recognized United applicable) along withthe below: ‘Slates jrldoion. + Completed Stato and Federal fingerprint card with $50.00 fee 6.50 fee payable to Treasurer, Stato of Connecticut for criminal history background checks; + Completed State and Fedoralflagerprint cards with $50.00 fee and a $16.50 fos payable to Treasurer, State of Connacticut for criminal history ‘background checks; CComplate this form and submit to DESPP, Division of State Police, pistol ppormit ocatlon along with tho below: + Completed Stale of CT and Federal : + Flieatms Safely & Use Course Firearms Safty & Use Course Certificate; end. fingerprint card with $60.00 fee and icatmenaltt + $70.00 payable to tho focal authority; $16.60 foo payablo to Troasuter, + $35.00 payable to Treasur + Proof you are legally and lawfully in the | State of Gonnecteut for eriminal State of Connecticut; United States (e.g., certified copy of bitty | history background checks: = Application for a State Eligibility certificate, U.S. passport or Eft Safely & Use Cotaee: Contiicate for a Pistol or ‘documentation issued by CE.) Corticate; Revolver or Long Guns (OPS- + $70.00 payable io Treasurer, State 64-C) and 2. Upon approval, the local authority will of Connecticut; + Proof you are legally and issue a Temporary Slate Permil to Carty Pistols | * Completed Appicalion for State issue a Temporary Si : Porm to Cary Pitas and gpa Rev (PSI) ect 0 pore ee a Comets D8 $28.5 tach 2x2 color photograph (passport ios Soh on rts oe ecb a hepato teono 0 Cary te ono ed youbygroropnsad Us Stos voice soy rage an atin tho Uo Stats eed cy + AcomltesApleaton fr Stl Pern | ate corteto 08 pasar or to Cnty Pts and Rovers (OFSE- | Son nsw by Lee) + $000 pay Trasurr, stato of Connect on lawfully in the United States (@4,, certified copy of bit certiicate, U.S. passport or documentation issued by I.C.E.). 3. Within the 60 day period, go lo a DESPP, Division of State Police, pistol permit location ‘and submit the following: + The Temporary State Perm to Carry Pistols and Revolvers (OPS-11-C) issued by the local authory, Note: All fees for all categories Provide Out of State Pistol Permit | 7° S@Parate Payments. + Proof you are legally and lawfully in the | Information: United States (e.g. certified copy of bith cortiicate, U.S. passport ot State of Issue: ‘documentation Issued by IC.) Expiration Date: + Your photograph will be taken at DESPP. Permit Number: DPS-799-C (Ren, 05/22/13) An Affirmative Action Equal Exployment Opportunity Employer Page 1 of 4STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION DIVISION OF STATE POLICE ‘Contact information/identifying information: ‘Namo of Applicant Last su Fit i ial oval oe as By GR You Tae ‘Maller, Aare, Wetman, SY {Attach additional sheet(s), if necessary) Taiear Be Sac Tian ia ACEO |e | Cie CC. |e us. | Ree Honea Om ee 5 ACCEOCOecenocoo co ee & sae Canty CHa Fea i a ooo | SSAoCAGACcio Residential Agarose (it ot adsreas: Pos fico box numbersare not acpi Tanbr/Sst i , OO. 1 GiyrFonn = a Sena sc Code sete reer Llst Renin! Adsronses forthe Last? Yours (lah adlonal shea) ,tnocssar) “Any subsequent changes of address must be reported within 48 hours to the Special Licensing and Firearms Unit ' 2 Mailin; (If different from current residential address above) = NumberStreet_ Giyffown Home Telophone Number doo odooo00 Cl fea Code mae SEES ey Tea [Employment Hibtory ee Eg z List Employers {or the Lost 7 Years (Provide amployore tame, adress and llophone number) (Aitach additonal sheot(s), if necessary) rms permit, permit application or eligibility certificate of any United Statos denied, suspended or revoked? []NO [] YES I'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-199-C (Res. 05/22/13) Au Affirmative Action Equal Employment Opportunity Employer Page 2 of 4STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION DIVISION OF 8 Have you beon confined ONO CYes ives a hospital for mental illness in the past sixty (60) months by order of a Probate Court? explain: (Attach additional sheol(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? (JNO LJ YES If°YES," explain: (Attach additional sheel(s), if necessary) Have you been voluntarily admitted to a hospital for mental iliness within the past six (8) months for reasons other than solely for alcohol or drug dependence? LINO [] YES IVES." explain: (Allach additional shee((s), necessary) Notice: Department of Emergency Services and Public Protection herein notes the applicant thet, pursuant fo Connecticut General Statutes Sections 29-28 through 29-8, DESPP will be notified by the Department of Mental Heaith and Addiction Services if the applicant fias been confined to @ hospital for psychiatric disabilities within the preceding sixty (60) months by order of probate court, or if the applicant has been voluntarily admitted to @ hospital for mentel fines within tho pasts (6) months for reasons ober than soley or alcool or dug dependence, gee Criminal History: Peek a Have you ever been ARRESTED for any crime, in any jurisdiction? CTNO CT YES W°VES." Ist all arress, indicating charges, locations, dates of arrest and dispositions. (Alach addllonal shee(s), i 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 lo C.G.S. 46b-146, 84-760, or 54-142a, If your criminal records have been erased pursuant to one of these statutes, you may swear under oath thal you have never been arrested. Criminal records that may be erased ate records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. 460- 146), an adjudication as a youthful offender (C.G.S. 84-760), a criminal charge that has been dismissed or nolled, a criminat charge for which the person has been found not guilly, or & conviction for which the person received an absolute pardon (CGS, 54-1428), 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 {rom another jurisdiction if you are permitted under the law of that jurisdiction to swear under oath thal you have never been arrested. Have you ever been CONVICTED under the laws of this state, federal law or the laws of another jurisdiction? TINO LI YES IVES," list all convictions, include charges, location, date of arrest, and disposiion. (Attach additional sheot(s), if necessary) ‘Are you currently on probation, parole, work release, in an alcohol andlor drug treatment program or other pre-trial diversionary program or currently released on personal recognizance, a written promise to appear or a bail bond fora pending court case? [JNO LJYES. If"YES," explain. (Attach additional sheel(s), if necessary) n the subjoct 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, regardloss of the outcome or result ‘of any related criminal case? [NO [] YES I°YES," which court issued the order? z B Military History: ‘Wore you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge? C] NO CI YES. “if you have ever been a member of the Armed Forces of the United Statos and have boon discharged, attach a copy of your DD-214 DPS-99.€ (Ren 05/2213) An Affirmative Action Equal Employment Opportunity Employer Page 3 of 4 |STATE OF CONNECTICUT IERGENCY SERVICES AND PUBLIC PROTECTION DIVISION OF STATE POLICE. DEPARTMENT OF = Proof of Trainings “attach a copy of the letter or certificate attesting that you have completed a course in the safely and use of pistols and revolvers or lang guns (as appropriate depending upon which permit or cortifcate you are requesting), signed by the instructor of the course. Instructor: (Check applicable box) {National Rifle Association [J Department of Energy and Environmental Protection (DEEP) other: State Instructor's Name and ID Number Tundorstand that any fais statement herein, which {do not believe tobe irue and whichis intended to mislead a public servant in the performance of his or her official function, is punishable by law (See CGS § 53a-157b). | further understand that any statement inthis application that is determined to be false or inaccurate shall constitute grounds for the danial of such application. If approved before the facts are known, such approval shall be void if based on a faise or inaccurate statement, My signature below altests to the accuracy, completeness and to the truth of al information supplied on this application: | declare, under the penalties of False Statement, that the answers to the above are true and correct. Date: Signed ae STATE OF Print Name couNTY oF Subscribed and sworn to before me this, day of 20. My Commission Expires: ‘Commissioner of Superior Court TINOTIGE: 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, 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. Contact Information for the Board of Firearm Permit Examiners, State Office Building, 20 Trinity St., Hartford, CT 06106. Telephone (860) 256-2977 or (800) 996-7078. Socgcooo [ce Remorse: Ne eter NCERewonme: No ‘sPBI: Uno ree DPS-799-C (Rev: 05/22/13) Au Affirmative Actiow/Equal Empleywent Opportunity Empleser Page 4 of 4To apply for a pistol permit, you must be 21 years of age or older ‘You are required to bring the following items to the Waterford Police Department: 1. Application for Permit to Carry Pistols and Revolvers (DPS-799), Application must be ‘Completed and Noti Current Color Passport Photograph (Can be obtained at CVS, Rite Aid, etc.) 2x2 in size. Original or Notarized Birth Certificate or Passport (copy will be made) Statement of Completion of Weapon Safety Course (copy can be made) Waterford Police Department Information Sheet found inside of packet, ‘One check or money order made payable to the Town of Waterford in the amount of $79.75, This includes the $50.00 State Fee, the $14.75 Federal Fee and the $15.00 Town of Waterford Fee, The fees are for fingerprints. YOU SHOULD BRING ALL INFORMATION DURING THE TIMES TO BE FINGERPRINTED FOR YOUR APPLICATION TO BE ACCEPTED IN ITS ENTIRETY. It takes approximately 8 weeks for the results of your application to be determined. You will be notified by the Waterford Police Department of the results. Should any information (ie, ‘Telephone Number, Address, ete.) change prior to determination please contact Kerri Cushman at (860) 442-0645, A fee of $70.00 will be collected at the time the permit is issued to you. We accept cash (exact amount) or check / money order made payable to the Town of Waterford, You will have 60 days from the date of issue to obtain your State Pistol Permit. We will provide the addresses of the State processing locations at the time you pick-up your temporary permit, The State requires an additional $70,00 fee due at the time of the issuance of your State Pistol Permit. Should you not obtain your State Pistol Permit within the 60 day time frame, your ‘Temporary Permit becomes null and void; therefore, requiting you to repeat the entire process (including all fees) again.“Waterford Police Department Information Sheet Inorder for us to assign your temporary pistol permit, please supply the following. information: Name of Employer. Address of Bouployer: ese Occupation:FINGER PRINTING SERVICES IN AN EFFORT TO FURTHER ENHANCE THE SERVICES WE PROVIDE YOU, THE TOWN OF WATERFORD POLICE DEPARTMENT HAS IMPLEMENTED. SET HOURS FOR FINGERPRINTING SERVICES (INKED IMPRESSIONS): WE HOPE YOU FIND THIS SCHEDULE HELPFUL* Aservice fee of $15.00 will be charged. This fee must be prepaid in either cash or by check payable to the “Town of Waterford”. (Please have exact change.) FOR PISTOL PERMIT APPLICANTS THIS FEE SHOULD BE INCLUDED IN THE CHECK TO THE TOWN OF WATERFORD FORA TOTAL OF $81.50. Re-takes of “obscured” prints will not be charged. *Prints will be completed in a timely manner, barring any unforeseen circumstances.