Form F-9r - Retired Law Enforcement Officer Firearms Qualification Application


Type of Application (Check One): Initial
Form F-9R (8/09)
Primary Address: ____________________________________________________________________________________
Street/P.O. Box
Zip Code
Primary Phone Number: (
) _____________________ E-mail Address:
Date of Birth: ____________ Sex: M
Last Four (4) Digits of Social Security Number: ________________
Law Enforcement Agency From Which Retired:
Agency Name
Applicant’s Certification
In making application to the North Carolina Criminal Justice Education and Training Standards Commission for Certification
under the Qualified Retired Law Enforcement Officers Firearms Qualification Certification Program, I hereby attest to the
I am a current resident of the State of North Carolina;
I retired in good standing from service with a public agency located in the United States as a law enforcement officer,
other than for reasons of mental instability;
Prior to retirement, I was authorized by law to engage in or supervise the prevention, detection, investigation, or
prosecution of, or the incarceration of, any person for any violation of law, and I had statutory powers of arrest;
Prior to retirement, I was regularly employed as a law enforcement officer for a total of 15 years or more, or retired after
completing probationary periods of service due to a service-connected disability, as determined by the agency;
I have a vested right to benefits under the retirement plan of the agency from which I retired;
I am eligible to receive or possess firearms under Federal and North Carolina Law;
I am not under indictment or information in any court for a felony, or any other crime, for which the judge could imprison
me for more than one year. (An information is the formal accusation of a crime by a prosecutor);
I have not been convicted in any court of a felony, or any crime, for which the judge could imprison me for more than one
year, even if I received a shorter sentence including probation;
I am not a fugitive from justice;
I am not an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other
controlled substance;
I have never been adjudicated mentally defective (which includes having been adjudicated incompetent to manage your
own affairs) and have never been committed to a mental institution;
I have never been discharged from the Armed Forces under dishonorable conditions;
I am not subject to a court order restraining me from harassing, stalking, or threatening my child or an intimate partner or a
child of such partner;
I have never been convicted in any court of a misdemeanor crime of domestic violence;
I have never renounced my United States citizenship; and,
I am not an alien illegally in the United States.
COUNTY OF ______________________________
I hereby certify that each and every statement made on this form is true and complete and I understand that any misstatement or
omissions of information will subject me to disqualification, suspension or revocation of my certification. I further understand
that any intentional and willful misrepresentation on this form may result in criminal prosecution.
This the ______ day of ________________________ , 20 _________ ______________________________________
Applicant’s Signature
Subscribed and sworn before me, this the ________ day of __________________________ , 20 ___________________
My Commission Expires: _________________ , 20 ____________
Notary Public - (Official Seal)


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