Form Dps-799-C (Rev. 05/27//15) - Pistol Permit/eligibility Certificate Application - State Of Connecticut Department Of Emergency Services And Public Protection Page 2
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4STATE 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
Race
:
/
/
.
F
Ft.
In.
Lbs
hite
American Indian/Alaskan Native
W
Month/Day/Year
M
Black
Asian/Pacific Islander
Unknown
Other
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
Motor Vehicle Operator’s License Number
Home Telephone 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:______________________________________
Page 2 of 4
DPS -799-C (Rev. 05/27//15)
An Affirmative Action/Equal Employment Opportunity Employer
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