Form Dps-799-C (Rev. 05/27//15) - Pistol Permit/eligibility Certificate Application - State Of Connecticut Department Of Emergency Services And Public Protection Page 3
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4STATE 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 ?
YES
If "YES,” list all convictions, include charges, location, date of arrest, and disposition. (Attach additional
NO
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:
Were you ever a member of the Armed Forces of the United States?
NO
YES (If yes, please include a copy of your DD-214)
Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge?
NO
YES
Page 3 of 4
DPS -799-C (Rev. 05/27//15)
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