WEST VIRGINIA STATE POLICE
APPLICATION FOR PROVISIONAL CONCEALED PISTOL/REVOLVER LICENSE
(This application must be completed in ink or by typewriter)
To the Sheriff of ___________________________ County, I, the below named applicant, swear/affirm, under penalty of law, that
the information contained within this application is true and correct to the best of my knowledge.
☐Initial ☐Honorably Discharged LEO☐Sheriff Waived
DATE SUBMITTED: ____/_____/_____ APPLICATION TYPE:
NAME:__________________________________________________________________ CONTACT #: _____________________________________
ADDRESS: ______________________________________________ ________________________________ ___________ _____________________
DOB: _______/________/_________ SSN: _________-_______-___________ PLACE OF BIRTH: _________________________________________
COUNTRY OF CITIZENSHIP: ________________________________ ALIEN/ADMISSION #: _______________________________ (If not US citizen)
HT: ________Ft._________In. WT: _____________ RACE: ________________ SEX: □M □F EYES: _____________ HAIR: ______________________
SCARS, MARKS, AND/OR TATTOOS (Description and location): _____________________________________________________________________
I am a bona fide resident of _____________________________ county, WV and present the following original, valid WV issued photo ID in support
of this assertion (Photocopy of ID must be attached to this application):
☐WV Driver’s License# ___________________
☐WV Non-Driver’s ID #______________________
☐Other (Describe) _________________
Answer each of the following questions by checking YES or NO:
Are you at least 18 and less than 21 years of age?
Are you addicted to alcohol, a controlled substance or drug, or are you an unlawful user thereof?
Have you been convicted of a felony?
Have you been convicted of an act of violence or an act of Domestic Violence?
Are you under indictment or do you have any criminal charges pending against you?
Are you currently serving a sentence of confinement, parole, probation or other court ordered supervision due to a
charge of domestic violence as provided for in 61-2-28 of the Code of West Virginia?
Are you the subject of a restraining order as a result of a domestic violence act as defined in 61-2-28 of the Code of
West Virginia or subject to a verified petition of domestic violence or subject to a protective order as provided for in
48-2a of the Code of West Virginia?
Have you ever been adjudicated to be mentally incompetent?
Do you have two (2) or more convictions for DUI related offenses?
10. In the last three (3) years prior to this application, have you been in a residential or court ordered treatment facility for
alcoholism and /or alcohol/drug detoxification treatment?
11. If you are applying for a license to carry a concealed handgun, have you qualified under the minimum requirements for
the handling and firing of a handgun as set forth in 61-7-4 of the Code of West Virginia? If YES, attach a copy of the
certificate of completion to this application. The Sheriff will determine applicability of this section to Retired Law
Enforcement Officers and Renewal Applicants.
12. Are you physically and mentally competent to carry a handgun
NOTE: If any of questions 2-10 listed above are answered YES, then a brief letter of explanation of each question must accompany this form.
I hereby authorize the Sheriff of _____________________________ County, to conduct an investigation into information contained in this
application. Furthermore, I understand that the falsification of any information contained within this application constitutes false swearing and
is a misdemeanor punishable under the provisions of 61-5-2 of the Code of West Virginia.
Applicant’s Signature X_________________________________________________________________ Date ______________________________