Form Dps-799-C (Rev. 05/22/13) - Pistol Permit/eligibility Certificate Application - State Of Connecticut Department Of Emergency Services And Public Protection Page 4
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4STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Proof of Training:
*Attach a copy of the letter or certificate attesting that you have completed a course in the safety and use of pistols and
revolvers or long guns (as appropriate depending upon which permit or certificate you are requesting), signed by the
instructor of the course.
Instructor: (Check applicable box)
National Rifle Association
Department of Energy and Environmental Protection (DEEP)
Other: ___________________________________
State Instructor's Name and ID Number:_______________________________________________________
Declaration:
I understand that any false statement herein, which I do not believe to be true and which is intended to mislead a public
servant in the performance of his or her official function, is punishable by law (See CGS § 53a-157b). I further understand
that any statement in this application that is determined to be false or inaccurate shall constitute grounds for the denial of
such application. If approved before the facts are known, such approval shall be void if based on a false or inaccurate
statement. My signature below attests to the accuracy, completeness and to the truth of all information supplied on this
application:
I declare, under the penalties of False Statement, that the answers to the above are true and correct.
Date: ____________________
Signed
STATE OF
Print Name
COUNTY OF _______________
Subscribed and sworn to before me this ______ day of
20_____
Name:
Notary Public
My Commission Expires:
Commissioner of Superior Court
NOTICE: Appeal Process for Permits
In the event that your application for pistol permit or eligibility certificate is denied or revoked, you may notify the
Board of Firearm Permit Examiners, in writing, within ninety (90) days, in order to begin your appeal process. At
a hearing before the Board, you may request that your application be reconsidered or that your permit or
eligibility certificate be reinstated. Contact Information for the Board of Firearm Permit Examiners, State Office
Building, 20 Trinity St., Hartford, CT 06106. Telephone (860) 256-2977 or (800) 996-7078.
For Official Use Only:
Application Received:
Application Status:
FBI Sent:
No
Yes
FBI Reply:
No
Yes
/
/
Approved
Denied
ICE Response:
No
Yes
Month/Day/Year
DMHAS:
No
Yes
SPBI:
No
Yes
(Signature and title of issuing authority)
Number :
Page 4 of 4
DPS-799-C (Rev. 05/22/13)
An Affirmative Action/Equal Employment Opportunity Employer
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