Ag Form 1r - State Of Maine Application For Permit To Carry Concealed Firearms (Page 3 of 6) in pdf

l. Have you ever been convicted of committing or found not criminally

responsible by reason of insanity or mental disease or defect of committing a

crime described in question (d)? ---------------------------------------------------------- YES

m. If your answer to question (l) is "yes," was that crime classified under the

laws of that state as a misdemeanor punishable by a term of imprisonment of

2 years or less?--------------------------------------------------------------------------------

YES

n. Have you ever been adjudicated as having committed a juvenile offense

described in question (h) or (i)? ---------------------------------------------------------- YES

o. Have you ever been adjudicated as having committed a juvenile offense

described in question (j)? ------------------------------------------------------------------ YES

p. Are you currently subject to an order of a Maine court or an order of a

court of the United States or another state, territory, commonwealth or tribe

that restrains you from harassing, stalking or threatening your intimate

partner, as defined in 18 United States Code, Section 921(a), or a child of your

intimate partner, or from engaging in other conduct that would place your

YES

intimate partner in reasonable fear of bodily injury to that intimate partner

or the child? ----------------------------------------------------------------------------------

q. Are you a fugitive from justice?-------------------------------------------------------- YES

r. Are you a drug abuser, drug addict or drug dependent person?---------------- YES

s. Do you have a mental disorder that causes you to be potentially dangerous

to yourself or others?------------------------------------------------------------------------

YES

t. Have you been adjudicated to be an incapacitated person pursuant to Title

18-A, Article V, Parts 3 and 4, and not had that designation removed by an

order under Title 18-A, M.R.S.A. § 5-307 (b)? [Termination of incapacity,

Probate Code; protection of persons under disability and their property] -----

YES

u. Have you been dishonorably discharged from the military forces within the

past 5 years?-----------------------------------------------------------------------------------

YES

v. Are you an illegal alien?----------------------------------------------------------------

YES

w. Have you been convicted in a Maine court of a violation of Title 17-A,

M.R.S.A. § 1057 [possession of a firearm in an establishment licensed for on-

premises consumption of liquor] within the past five (5) years?--------------------

YES

x. Have you been adjudicated in a Maine court within the past five (5) years

as having committed a juvenile offense involving conduct that, if committed

by an adult, would be a violation of Title 17-A, M.R.S.A. § 1057 [criminal

possession of a firearm in an establishment licensed for on-premises

YES

consumption of liquor]?--------------------------------------------------------------------

y. To your knowledge, have you been the subject of an investigation by any

law enforcement agency within the past 5 years regarding the alleged abuse

YES

by you of family or household members?-----------------------------------------

PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED

Initials______

AG Form 1R (8/06)

Page 3 of 6

Ag Form 1r - State Of Maine Application For Permit To Carry Concealed Firearms Page 3

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