Ag Form 1r - State Of Maine Application For Permit To Carry Concealed Firearms
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6MAKE CHECK PAYABLE TO: TREASURER, STATE OF MAINE
FOR OFFICE USE ONLY
STATE OF MAINE
CHECK #
___ $35.00 ____$20.00
LICENSE #
____ $2.00
APPLICATION FOR PERMIT TO
CARRY CONCEALED FIREARMS
_____
_____
:________
ISSUE
DENIED
DATE
(Resident)
NEW
RENEWAL
($35.00)
($20.00)
EXPIRATION DATE (IF ISSUED)__________
KNOWLEDGE OF HANDGUN SAFETY:
CHANGE OF ADDRESS
($2.00)
FULL NAME (First, Middle, Last)
PREVIOUS LEGAL NAMES, IF ANY (List month and year each name was given/assumed)
ALIASES, IF ANY (List year(s) used)
CITIZEN
EYECOLOR
COLOR OF
BIRTHDATE
BIRTHPLACE
HT
WT
SEX
RACE
HAIR
(Y/N)
MAILING ADDRESS (If different than legal residence)
CITY OR TOWN
STATE
ZIP CODE
FULL CURRENT RESIDENCE ADDRESS
CITY OR TOWN
STATE
ZIP CODE
(Street or Road Name, not P.O. Box)
LIST OF ALL ADDRESSES AT WHICH YOU HAVE LIVED AT ANY TIME DURING THE PAST FIVE (5) YEARS
(Street or Road, City/Town, State, Zip, Dates of residence)
LIST OF PREVIOUSLY ISSUED PERMITS TO CARRY CONCEALED FIREARMS OR OTHER CONCEALED
WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR ANY OTHER JURISDICTION. For each permit
previously issued, please identify the issuing authority (e.g. Massachusetts State Police; Portland P.D.; Town of
Shapleigh, Selectmen) and the date the permit was issued.
LIST OF PREVIOUS REFUSALS TO ISSUE PERMIT TO CARRY CONCEALED FIREARMS OR OTHER
CONCEALED WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR IN ANY OTHER JURISDICTION. For
each refusal of a permit, please identify the agency that refused to issue the permit, and the date of refusal.
LIST OF PREVIOUS REVOCATIONS OR SUSPENSIONS OF FIREARMS PERMITS OR PERMITS TO CARRY
CONCEALED FIREARMS OR OTHER CONCEALED WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR
IN ANY OTHER JURISDICTION. For each revocation, please identify the agency or authority that revoked the permit
and the date it was revoked or suspended.
PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED
Initials______
AG Form 1R (8/06)
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