Concealed Handgun Carry License Application Form

30. Are you the subject of a court order, such as a restraining or protection order, that

restrains you from harassing, stalking or threatening your child, intimate partner or

child of the intimate partner? __________ If yes, please provide a copy of the court order.

31. Have you ever renounced your United States Citizenship? ___________________

QUESTIONS RELATING TO ARKANSAS LAW

32. Are you a citizen of the United States?

__________________

If yes, do you declare allegiance to the United States Constitution and the

Arkansas Constitution? _____________________

If no, are you a permanent legal resident of the United States? _____________

Please attach proof of your current status.

33. Have you been a resident of Arkansas continuously for at least ninety (90) days

prior to the signing of this application? _________________

34. Have you been furnished with a copy of ACA §§5-73-301 et seq. (the Arkansas

concealed handgun carry licensing law) and are you acquainted with the truth and

understanding of this subchapter? _____________

35. Are you at least twenty-one (21) years of age at the time of signing this application?

____________ If no, are you at least eighteen (18) years of age and a current or former

active duty member of the United States military? _______________Please provide proof of

that status.

36. Do you desire a legal means to carry a concealed handgun to defend yourself? _____

37. Are you applying for an unrestricted license? ____________________________________

I hereby state that all information on this application is correct. I understand that

knowingly giving a false statement or submitting a false document will subject me to

criminal prosecution, preclude future concealed handgun license issuance, and/or

immediate revocation of any license already issued by the Department.

I give my consent and release to the Arkansas State Police to conduct a thorough

investigation into my qualifications to be licensed to carry a concealed handgun, for any

records or reports held by any physician, medical professional, medical facility, mental

institution (private, state or federal) or for any law enforcement agency to furnish

detailed information from their records as it relates to my application. I agree that I

shall sign any additional releases as may be required by health care providers to achieve

this purpose. A copy of this authorization shall serve in the place of and the same as

the original. This release is continuing in force and effect so as long as I hold or attempt

to hold an Arkansas concealed handgun carry license.

Signature: _________________________________________________ Date: ____________________

(First/MI/Last Name)

(Month/Day/Year)

Revised November 2015

Concealed Handgun Carry License Application Form - 2015 Page 4