S.t.s. 033 - Application For Firearms Purchaser Identification Card And/or Handgun Purchase Permit - State Of New Jersey Page 2

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STATE OF NEW JERSEY

Application for Firearms Purchaser Identification Card and/or Handgun Purchase Permit

This form is prescribed by the Superintendent for use by applicants for Firearms Purchaser I.D. Cards & Handgun Purchase Permits. Any alteration to this form is expressly forbidden.

Check Appropriate Block(s)

Initial Firearms Purchaser Identification Card

Change of name on Identification Card

Lost or Stolen Identification Card

List former name and attach copy of marriage license or court order

Mutilated Identification Card

Change of Address on Identification Card

Change of Sex on Identification Card

Application to Purchase a Handgun

Quantity of Permits:

(1) NAME

Last ( If female, include maiden)

First

Middle

(2) SOCIAL SECURITY NUMBER

(3) RESIDENCE ADDRESS

Number & Street

City

State

Zip

(4) HOME TELEPHONE

(

)

(5) DATE OF BIRTH

(6) AGE

(7) PLACE OF BIRTH

City, State, Country

(8) DRIVER'S LICENSE NUMBER & STATE

(9) SEX

RACE

HEIGHT

WEIGHT

HAIR

EYES

(10) DIST. PHYSICAL CHARACTERISTICS

(11) U.S. CITIZEN

(Marks, Scars, Tattoos)

Yes

(12) NAME OF EMPLOYER

EMPLOYER'S ADDRESS & TELEPHONE

(13) OCCUPATION

(14) ADDRESS APPEARING ON FORMER FIREARMS IDENTIFICATION CARD (If Applicable)

(15) N.J. FIREARMS ID CARD/SBI NUMBER

(16) Have you ever been convicted of any domestic violence offense in any jurisdiction which involved the elements of (1) striking, kicking, shoving, or (2)

Yes

purposely or attempting to or knowingly or recklessly causing bodily injury, or (3) negligently causing bodily injury to another with a deadly weapon? If yes, explain.

(17) Are you subject to any court order issued pursuant to Domestic Violence? If yes, explain.

Yes

(18) Have you ever been adjudged a juvenile delinquent? If yes, list date(s), place(s), and offense(s).

Yes

(19) Have you ever been convicted of a disorderly persons offense in New Jersey or any criminal offense in another jurisdiction where you could have been

Yes

sentenced up to six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and offense(s).

(20) Have you ever been convicted of a crime in New Jersey or a criminal offense in another jurisdiction where you could have been sentenced to more than

Yes

six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and crime(s).

(21) Do you suffer from a

(22) If answer to question 21 is yes, does this make it unsafe for you to handle firearms? If not, explain.

Yes

physical defect or disease?

(23) Are you an alcoholic?

(24) Have you ever been confined or committed to a mental institution or hospital for treatment or observation of a

Yes

mental or psychiatric condition on a temporary, interim, or permanent basis? If yes, give the name and location of the

institution or hospital and the date(s) of such confinement or commitment.

(25) Are you dependent

(26) Have you ever been attended, treated or observed by any doctor or psychiatrist or at any hospital or mental

Yes

upon the use of a narcotic(s)

institution on an inpatient or outpatient basis for any mental or psychiatric condition? If yes, give the name and location

or other controlled

of the doctor, psychiatrist, hospital or institution and the date(s) of such occurrence.

dangerous substance(s)?

(27) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, permit to carry a handgun or any other firearms license or

Yes

application refused or revoked in New Jersey or any other state? If yes, explain.

(28) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of force and violence, either

Yes

to overthrow the Government of the United States or of this State, or which seeks to deny others their rights under the Constitution of either the United States or

the State of New Jersey? If yes, list name and address of organization(s).

(29) Names, Addresses and Telephone Numbers of two reputable persons who are presently acquainted with the applicant, other than relatives:

APPLICANT: DO NOT WRITE BELOW THIS SPACE

I hereby certify that the answers given on this application are complete, true and correct

A non-refundable fee of $5.00 for a F irearms Purchaser Identification Card (Initial

in every particular. I realize that if any of the foregoing answers made by me are false, I

Firearms Purchaser ID card only) and/or $2.00 for each Permit to Purchase a Handgun,

am subject to punishment.

payable to the Superintendent of State Police or the Chief of Police in the municipality in

which you reside, must accompany this application.

(30)

IDENTIFICATION CARD/PERMIT NUMBER(S)