Fillable Form Dps-67-C - Application To Purchase A Firearm printable pdf download

APPLICATION TO PURCHASE A FIREARM –

C.G.S. §§ 29-33 AND 29-37a

WEAPON TYPE

HANDGUN

LONG GUN

OTHER

SALE AUTHORIZATION NUMBER(S)

Name:

Date of Birth:

(Last, First, Middle)

(MM/DD/YYYY)

Address:

Include number, street, town, state and zip (Post Office boxes not accepted)

Sex:

Race:

Height:

Weight:

Eye Color:

Hair Color:

Social Security Number:

Country of Citizenship:

ICE Number:

(optional)

(required)

(if applicable)

Pistol Permit Number/Eligibility Certificate Number:

Expiration Date:

(required)

Police Identification Number:

Agency Name:

Driver’s License Number:

State:

Expiration Date:

(required)

(MM/DD/YYYY)

a. Have you been convicted of a felony?

Yes

b. Have you ever been convicted of a misdemeanor crime of domestic/family violence?

Yes

c. Are you the subject of an active 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

d. Have you ever been confined to a hospital for persons with psychiatric disability (C.G.S. § 17a-495) within the preceding sixty (60) months

by order of a Probate Court?

Yes

e. Have you been voluntarily admitted to a hospital for persons with psychiatric disabilities, within the preceding six (6) months for

reasons other than solely for alcohol or drug dependence?

Yes

f. Have you been discharged from custody within the preceding twenty (20) years after having been found not

guilty of a crime by reason of mental disease or defect pursuant to Connecticut General Statutes Section 53a-13?

Yes

g. Are you the subject of a court issued risk warrant to seize firearms pursuant to C.G.S. § 29-38c(d)?

Yes

h. Have you ever had an application to purchase a firearm denied in any other State?

Yes

If so, Where

When?

Reason for denial?

i. Have you ever been convicted of any of the following misdemeanors?

Yes

If yes, check all that apply.

Illegal possession of controlled or hallucinogenic substances (C.G.S. § 21a-279(c))

Criminally negligent homicide (C.G.S. § 53a-58)

Unlawful restraint 2

(C.G.S. § 53a-96)

Assault in the 3

(C.G.S. § 53a-61)

Riot 1

(C.G.S. § 53a-175)

Assault of a victim 60 or older in the 3

(C.G.S. § 53a-61a)

Riot 2

(C.G.S. § 53a-176)

Threatening 2

(C.G.S. § 53a-62)

Inciting to riot (C.G.S. § 53a-178)

Reckless endangerment 1

(C.G.S. § 53a-63)

Stalking 2

(C.G.S. § 53a-181d)

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. 13-3 as amended by P.A. 13-220, P.A. 98-129, and 18 U.S.C. 922, 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 CONNECTICUT GENERAL STATUTES SECTIONS 29-34 AND/OR 29-37e AND CONSTITUTES A CLASS D FELONY OR IN SOME

CASES, A CLASS B FELONY.

SIGNATURE OF PURCHASER

DATE

I UNDERSTAND THAT A PERSON WHO ANSWERS, “YES” TO QUESTIONS A-G IS PROHIBITED FROM PURCHASING A FIREARM. THOSE

APPLICANT’S ANSWERING IN THE AFFIRMATIVE TO QUESTIONS H AND I, MAY BE PROHIBITED UPON COMPLETION OF A BACKGROUND

CHECK.

SIGNATURE OF SALESPERSON

DEALER NAME, IF APPLICABLE

DATE

THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY THE SELLER AND PURCHASER

DPS-67-C (Rev. 06/30/13-

) An Affirmative Action/Equal Employment Opportunity Employer

Previous editions are obsolete

Form Dps-67-C - Application To Purchase A Firearm

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