Application For Concealed Firearm Instructor Renewal (Page 2 of 2) in pdf

State of Utah

Department of Public Safety

APPLICATION FOR CONCEALED FIREARM INSTRUCTOR RENEWAL

Your application will not be processed unless this form is completely filled out and all applicable questions have been

answered. Be sure to provide all supporting documents. Enclose the appropriate fee $25.00 (include $7.50 late fee if the

license is more than 30 days expired) in the form of cash, check, money order or credit card made payable to “Utah Bureau

Bureau Use Only

of Criminal Identification.” FEES ARE NON-REFUNDABLE.

Please read all instructions prior to completing this form. TYPE OR PRINT IN INK.

Name__________________________________________________________Date of Birth__________________Place of Birth____________________

(Last)

(First)

(Middle)

Previously used Name(s)(Maiden, etc.)_______________________________________________Social Security Number____________________

Address_________________________________________________________________________________________________________________

(Street)

(City)

(County)

(State)

(Zip)

Mailing Address (if different from street address)__________________________________________________________________________

Home Phone#_________________________Work Phone #___________________________Driver Lic # ____________________________ST. _____

Height_______________Weight_______________Eye Color_______________Hair Color_______________Sex___________Race____________

What is your Citizenship?__________ Alien Registration # or Naturalization #____________________________Utah Instructor #__________________________

ALL APPLICANTS: Please answer “Yes” or “No” to all questions below. A complete criminal background check will be conducted including

expunged and juvenile court records. If you answer “Yes” to any question, attach documentation explaining your answer.

☐ Yes

☐ No

Have you ever been convicted of a felony?

☐ Yes

☐ No

Have you ever been convicted of a crime of violence?

☐ Yes

☐ No

Have you ever been convicted of an offense involving the use of alcohol? (i.e. DUI/DWI, alcohol related reckless, unlawful use of alcohol, etc.)

☐ Yes

☐ No

Have you ever been convicted of the unlawful use of narcotics or other controlled substances?

☐ Yes

☐ No

Have you ever been convicted of any offense involving moral turpitude? (i.e., theft, criminal mischief, sex crimes, etc.)

☐ Yes

☐ No

Have you ever been convicted of offense involving domestic violence?

☐ Yes

☐ No

Have you ever been adjudicated as mentally incompetent?

☐ Yes

☐ No

Are you currently subject to a court sanctioned protective order?

☐ Yes

☐ No

Have you ever been dishonorably discharged from the armed forces?

Instructors desiring to be listed on the BCI website MUST supply a valid phone number and/or e-mail for customer contact.

PHONE

EMAIL OR WEBSITE ADDRESS_______________________________________________________

This information must be current at all times, if changed BCI must be notified immediately.



Please check this box if you DO NOT want your name and number on our website.

ALL APPLICANTS: Please read and sign the statement below.

I understand that it is a class B misdemeanor to knowingly and willfully provide false information on an application for certification as a concealed firearms permit instructor and

may result in the denial of certification pursuant to Utah Code Ann. § 53-5-704(15). I hereby declare under criminal penalty of the State of Utah that the information contained on

this application is true and correct.

Signed on: _____________________

(Date)

____________________________________

(Signature)

METHOD OF PAYMENT (CHECK APPROPRIATE BOX)

Payment enclosed (check or money order only)

Credit Card

Credit Card payment must include 3 or 4-digit control number found on the back of the credit card. There is a $20.00 service charge for any returned check.

Credit Card Signature_________________________________________________________ Zip Code Associated with Credit Card___________________________

*Visa ☐

*MasterCard ☐

*AMEX ☐

Credit Card Orders:

Card Number – 15 digit AMEX or 16 digit Visa or MasterCard

3 or 4 digit control #

Expiration Date

Utah Bureau of Criminal Identification 3888 W 5400 S Taylorsville Utah 84129 (801) 965-4445 - - - - - BCI-1523C-0306

Revised 8/2015