Form Dps-67-C - Application To Purchase A Firearm - 2011
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1APPLICATION TO PURCHASE A FIREARM -
SECTIONS 29-33 AND 29-37a OF THE CONNECTICUT GENERAL STATUTES
WEAPON TYPE:
HANDGUN
LONG GUN
OTHER SALE AUTHORIZATION NUMBER (S): ____________________
NAME: ____________________________________________________ DATE OF BIRTH: ____________
LAST
FIRST
MIDDLE
MM/DD/YYYY
RESIDENTIAL ADDRESS: __________________________________________________________________
(POST OFFICE BOXES NOT ACCEPTED)
NUMBER
STREET
TOWN
STATE
ZIP
SEX: ___ RACE: ___ HEIGHT: _____ WEIGHT: _____ EYE COLOR: _______ HAIR COLOR: _______
SOCIAL SECURITY #: ____________ COUNTRY OF CITIZENSHIP: _____________ ICE #: ___________
OPTIONAL
REQUIRED
IF APPLICABLE
PISTOL PERMIT/ELIGIBILITY CERTIFICATE #: ________________ EXPIRATION DATE: ___________
MM/DD/YYYY
POLICE IDENTIFICATION #: ________________ AGENCY NAME: _______________________________
DRIVERS LICENSE #: ______________________ STATE: _____ EXPIRATION DATE: _______________
REQUIRED
MM/DD/YYYY
HUNTING LICENSE #: _______________________
LONG GUNS ONLY
a.
Have you ever been convicted in any court of a felony?
Yes
No
b.
Have you been convicted in any court of a misdemeanor crime of domestic/family violence?
Yes
No
c.
Are you now the subject of a restraining or protective order issued by a court, after notice
and an opportunity to be heard has been provided to you, in a case involving the use,
attempted use or threatened use of physical force against another person?
Yes
No
d.
Have you ever been confined in a hospital for a mental illness within the past twelve (12)
months by order of a probate court?
Yes
No
e.
Have you been discharged from custody within the past twenty (20) years after having
been found not guilty of a crime by reason of mental disease or defect?
Yes
No
f.
Are you the subject of a court issued seizure order (risk warrant) per CGS 29-38c?
Yes
No
Information provided on this application is subject to verification from sources including probate, civil, and criminal courts as well as
governmental agencies pursuant to State and Federal Law, e.g., P.A. 98-129 (An Act Concerning Handgun Safety) and 18 USC 922
(The Brady Act), as may be amended.
I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE
INFORMATION ON THIS DOCUMENT IS A VIOLATION OF SECTION 29-34 AND/OR 29-37e OF THE
CONNECTICUT GENERAL STATUTES AND CONSTITUTES A CLASS D FELONY.
___________________________________________
_________________
SIGNATURE OF PURCHASER
DATE
I UNDERSTAND THAT A PERSON WHO ANSWERS, “YES” TO ANY OF THE ABOVE QUESTIONS IS PROHIBITED
FROM PURCHASING A FIREARM.
________________________________
_________________________________
_________________
SIGNATURE OF SALESPERSON
DEALER NAME IF APPLICABLE
DATE
DPS-67-C (Revised 7-11) Previous editions are obsolete
THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY THE SELLER AND PURCHASER
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