Chl-78c, Reported History Form printable pdf download

Texas Department of Public Safety

HANDGUN LICENSING

Regulatory Services Division

REPORTED HISTORY FORM

APPLICANT NAME

CRIMINAL HISTORY INFORMATION

(*USE ADDITIONAL PAGES AS NECESSARY.)

Indicate all criminal history information, regardless of the amount of time that has passed or in which state the offense occurred. Include

juvenile cases, any assaults of any level and disposition in court, all charges that were dismissed, deferred adjudications and all pending

charges, whether or not you believe these are disqualifying.

Date of Arrest

Arresting Agency and Location

Offense

Full Disposition

(MM/DD/YYYY)

(COUNTY AND STATE)

Have you ever received a dishonorable discharge from the military?  Yes  No * If yes, you must submit a copy of your DD-214.

I acknowledge I have reviewed the eligibility criteria, disqualifying offenses and the definition of ‘conviction’ provided in the Texas

Handgun Licensing Laws, Administrative Rules and of the Penal Code.  Yes  No

Have you had a maiden and/or alias name, different from what is listed on your application?

 Yes  No *If yes, please list all:

TREATMENT HISTORY INFORMATION

* USE ADDITIONAL PAGES AS NECESSARY.

Indicate any history or information, of treatment and/or diagnosis received by, commitment to, or residence in:

● a drug or alcohol treatment center licensed to provide drug or alcohol treatment under the laws of this state or another state; OR

● a psychiatric hospital; OR

● a mental institution following an adjudication as a mental defective or court ordered commitment or treatment (per 18 U.S. Code

§ 922(g) (4)); OR

● court ordered outpatient treatment; OR

● a physician for a psychiatric disorder or condition that causes or is likely to cause substantial impairment in judgment, mood,

perception, impulse control, or intellectual ability (per Texas Government Code § 411.172(d)(1)).

Date

Location

Facility

Final Diagnosis

(MM/DD/YYYY)

(INCLUDE COUNTY AND STATE)

CHL-78C (Rev. 12/15)

Chl-78c, Reported History Form