Form Fir-652-010 Alien Firearm Lic App - Alien Firearm License Application - Department Of Licensing Of Washington Page 2

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DEPARTMENT OF LICENSING
FIREARMS SECTION
STATE OF WASHINGTON
PO BOX 9649
OLYMPIA, WA 98507-9649
ALIEN FIREARM LICENSE APPLICATION
For Validation Only
001-070-236-0003
Last Name
First
Middle
List any other names by which you have been known
Residential Address
City
State
Zip
! Yes
! No
Have you been a resident of Washington State for the last consecutive 24 months?
Date of Birth
Birthplace
Phone no. (
)
MO
DAY
YR
OPTIONAL
Race
Sex
Weight
Height
Eyes
Hair
Dr. Lic./ID #
List type and location of all marks, scars or tattoos
ANSWER THE FOLLOWING WITH "YES" OR "NO"
1. Have you ever been convicted in adult court or adjudicated in a juvenile court, in this state or
elsewhere of one of the prohibitive crimes described on the back of this form?
2. Are you now on bond or personal recognizance pending trial, appeal or sentence for any
felony offense?
3. Are you the subject of an outstanding arrest warrant from any court for any crime?
4. Have you been convicted of three or more violations of Washington’s firearms laws within any five-
year period?
5. Have you had a firearm forfeited in the last five years for a drug or alcohol incident pursuant to
RCW 9.41.098 (1) (e)?
6. Are you under a court order or an injunction concerning the possession of a firearm?
7. Is your concealed pistol license, if any, in a revoked status?
8. Have you ever been confined in a mental health facility for more than 14 days for treatment, or
committed as criminally insane?
If you answered “yes” to any of the above eight questions, but believe you are nonetheless eligible for a license,
attach a list of dates and circumstances including copies of any applicable pardons, certificates of rehabilitation,
or court orders.
Note: A signed application shall constitute a waiver of confidentiality and written request that the Department
of Social and Health Services, as well as mental health institutions and other health care facilities, release
information relevant to the applicant’s eligibility for a concealed pistol license to an inquiring court or law
enforcement agency.
I certify or declare under penalty of perjury under the laws of the State of Washington, that the foregoing is true
and accurate.
X
Signature
Date
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360) 753-2803 or TTY (360) 586-2788.
FIR-652-010 ALIEN FIREARM LIC APP (R/9/00)FM/W Page 2 of 3

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