Application For A Licence Under The Firearms Act (Pal) (For Individuals Aged 18 And Over) Page 2
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5PART D: PERSONAL HISTORY
A "YES" answer does not necessarily mean your application will be refused; it may lead to further examination.
IF YOU HAVE RECEIVED A PARDON FOR ANY ITEM LISTED BELOW, YOU ARE NOT REQUIRED TO REPORT THAT ITEM.
17a) During the past five years, have you been charged, convicted or granted a discharge for an offence:
(i) under the Criminal Code or the Young Offenders Act where violence was used, threatened or attempted;
(ii) involving the misuse, possession, or storage of a firearm; or
Yes
No
(iii) involving trafficking or importing drugs or controlled substances?
17b) During the past five years, have you been subject to a peace bond or a protection order?
Yes
No
17c) During the past five years, have you or any member of your household been prohibited from possessing any firearm?
Yes
No
17d) During the past five years, have you threatened or attempted suicide, or have you been diagnosed or treated by a medical
Yes
No
practitioner for: depression; alcohol, drug or substance abuse; behavioural problems; or emotional problems?
17e) During the past five years, do you know if you have been reported to the police or social services for violence, threatened or
Yes
No
attempted violence, or other conflict in your home or elsewhere?
17f) During the past two years, have you experienced a divorce, a separation, a breakdown of a significant relationship,
Yes
No
job loss or bankruptcy?
If you answer YES to any of the questions in Part D, please provide details on a separate page.
* PART E: INFORMATION ABOUT SPOUSE / COMMON-LAW PARTNER YOU ARE LIVING WITH. Provide information on the spouse or
common-law partner with whom you are currently living. (See Information Sheet)
Not applicable. I am not living with a spouse or common-law partner.
Your spouse or common-law partner will be notified of this application if he or she has not signed below.
18a) Spouse or common-law partner's last name
18b) Spouse or common-law partner's first name
18c) Date of birth (Y-M-D)
FOR ANY SAFETY CONCERNS ABOUT THIS APPLICATION, PLEASE CALL 1 800 731-4000.
18d) Telephone number and time when he/she may be contacted
18e) Signature of spouse or common-law partner
18f) Date (Y-M-D)
day
(
)
evening
* PART F: INFORMATION ABOUT SPOUSES / COMMON-LAW PARTNERS YOU ARE NO LONGER LIVING WITH. Provide information on any
spouse or common-law partner (other than any person named in Part E above) with whom you have lived at any time during the past 2 years.
(See Information Sheet)
Not applicable. I have not lived with a spouse or common-law partner in the past 2 years (other than any person named in Part E above).
Your former spouse(s) or common-law partner(s) will be notified of this application if they have not signed below.
19a) Former spouse or common-law partner's last name
19b) Former spouse or common-law partner's first name
19d) Telephone number and time when he/she may be contacted
19c) Date of birth (Y-M-D)
day
(
)
evening
19e) Street / Rural route / PO Box number
19f) Apt. / Unit
19g) City
19h) Province / State
19i) Country
19j) Postal / Zip code
I declare that I do not know the current address and/or telephone number of my former spouse / common-law partner.
FOR ANY SAFETY CONCERNS ABOUT THIS APPLICATION, PLEASE CALL 1 800 731-4000.
19k) Signature of former spouse or common-law partner
19l) Date (Y-M-D)
PART G: SAFETY TRAINING CERTIFICATION (See Information Sheet)
* 20a) Have you passed the Canadian Firearms Safety Course test?
Province
Date (Year)
No
Yes
If yes
Proof attached (if available)
* 20b) Have you passed the Canadian Restricted Firearms Safety Course test?
Province
Date (Year)
No
Yes
If yes
Proof attached (if available)
* 20c) Have you been otherwise certified by the Chief Firearms Officer as meeting the safety training requirements or have you successfully
completed a course approved by the Attorney General of Manitoba or Quebec?
No
Yes
If yes, specify
Proof attached
CAFC 1039 E (2004/04/15)
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