Fir-652-007 - Concealed Pistol License Application -

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Concealed Pistol License Application

ID number __________________

SID number ________________

PRINT or TYPE all information.

FBI number _________________

Application type

CPL number ________________

Original application

Renewal of license

Late renewal of license

Replacement license

Name (Last, First, Middle)

CPL number, if applicable

Expiration date

Other names by which you have been known (for example: maiden name)

Driver license number

State

–

Physical address

required

City

State

ZIP code

Mailing address (if different)

City

State

ZIP code

Date of birth

Birthplace (City, State/Province, Country)

(Area code) Telephone number (optional)

Gender

Male

Female

Height

Weight

Eyes (color)

Hair color

Ethnicity

feet

inches

pounds

Hispanic or Latino

Not Hispanic or Latino

Race (Check all that apply)

Black or African American

American Indian or Alaska Native

White

Asian

Native Hawaiian or Other Pacific Islander

List type and location of all marks, scars, and tattoos

Residency

1. Are you a U.S. citizen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If no, enter country of citizenship

2. Are you a permanent resident alien? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If yes, enter your permanent resident card number

3. Are you a legal alien temporarily residing in Washington? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If yes, enter your alien registration/I-94 number

and;

Enter your alien firearms license number:

Expiration date:

Answer the following

1. Have you ever been convicted in adult court or adjudicated in a juvenile court of the following crimes when committed by

one family or household member against another, on or after July 1, 1993: assault in the fourth degree, coercion,

stalking, reckless endangerment, criminal trespass in the first degree, or violation of the provision of a

protection order or no-contact order restraining the person or excluding the person from a residence?. . . . . .

Yes

2. Are you now on bond or personal recognizance pending trial, appeal or sentence for any serious

offense as defined in RCW 9.41.010 or for a felony for any crime where the judge can imprison

you for more than one year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

3. Have you been convicted of 3 or more violations of Washington’s firearms laws within any 5-year period? . . .

Yes

4. Are you an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or

any other controlled substance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

5. Have you ever been adjudicated mentally defective (which includes having been adjudicated

incompetent to manage your own affairs) or have you ever been committed to a mental institution? . . . . . . . .

Yes

6. Have you been discharged from the Armed Forces under dishonorable conditions? . . . . . . . . . . . . . . . . . . . .

Yes

7. Are you subject to a court order restraining you from harassing, stalking, or threatening your child

or an intimate partner or child of such partner? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

8. Have you been convicted in any court of a misdemeanor crime of domestic violence? . . . . . . . . . . . . . . . . . .

Yes

9. Have you ever renounced your United States citizenship? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

10. Are you an alien illegally in the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Signing this application authorizes the Department of Social and Health Services, as well as mental-health institutions and

other health-care facilities, to release information relevant to your eligibility for a concealed pistol license to an inquiring court

or law-enforcement agency.

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Applicant signs here

Date and place signed

Applicant signature

FIR-652-007 (R/8/15)WA Page 1 of 2