S.t.s. 033 - Application For Firearms Purchaser Identification Card And/or Handgun Purchase Permit - State Of New Jersey Page 3

Download a blank fillable S.t.s. 033 - Application For Firearms Purchaser Identification Card And/or Handgun Purchase Permit - State Of New Jersey in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete S.t.s. 033 - Application For Firearms Purchaser Identification Card And/or Handgun Purchase Permit - State Of New Jersey with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

CLEAR FORM

N.J.S.A. 30:4-24.3 provides that all records

CONSENT FOR

of any individual's commitment to a non-

MENTAL HEALTH RECORDS SEARCH

correctional in sti tu tion for mental health

reasons shall be con fi den tial and shall not

This consent MUST be completed by the firearm ap pli cant.

be disclosed ex cept in lim it ed circumstanc-

Failure to consent requires denial or dis ap prov al of the application.

es or with the consent of the in di vid u al.

PART ONE (To be completed by the applicant)

Name: (Last, Maiden, First, MI)

Date of Birth: (Month, Day, Year)

Social Security Number:

Address: (Number & Street)

(Municipality)

(County)

(State)

List Prior Addresses for past 10 years:

NOT APPLICABLE

ADDRESS 1: Dates Resided

From: ________________________ To: ________________________

(Number & Street)

(Municipality)

(County)

(State)

ADDRESS 2: Dates Resided

From: ________________________ To: ________________________

(Number & Street)

(Municipality)

(County)

(State)

I, __________________________________________________ am aware of my rights under N.J.S.A. 30:4-24.3, and the

Health Insurance Portability and Insurance Accountability Act (HIPAA), 45 C.F.R. 164.50, and consent to the disclosure of

my mental health records to the Chief of Police and the Su per in ten dent of State Police, or their designees, for the purpose of

verifying my ﬁ rearms permit application and my ﬁ t ness to own a ﬁ re arm under N.J.S.A. 2C:58-3. I understand that copies

of this authorization shall be considered sufﬁ cient authorization for the release of records.

Investigating Police Department

Witness (Print Name)

Signature of Witness

Signature of Applicant

Date

The disclosure of my Social Security Number is voluntary. Without this number, the processing of my application may be delayed. This number is considered conﬁ dential.

PART TWO (To be completed by County Adjuster's Office, Mental Health Institution and/or Doctor)

Record of Admission

Date of

Signature of Authorized

Commitment or Treatment

Check

Official or Doctor

(Dr.: Provide Medical License #)

Yes

Expunged

__________________________________________________

______________ ________________________