Looking for a Firearm License Application Form Templates? Download it for free!

State of Utah

Department of Public Safety

APPLICATION FOR CONCEALED FIREARM PERMIT

Revised 8/200

Please read all instructions prior to completing this form. TYPE OR PRINT IN INK.

Your application will not be processed unless this form is completely filled out and all applicable questions answered. Be

sure to provide all supporting documents: one complete fingerprint card, one photo (with name on back), photocopy of

resident state’s permit (if applicable) with expiration date visible and photocopy of drivers’ license.

Bureau Use Only

$39.00 for Utah residents or $49.00 for non-residents

Enclose the appropriate fee,

in the form of credit card, money order or check made payable to

“Utah Bureau of Criminal Identification”. Name and address must be imprinted on check

Cannot accept foreign credit cards.

FEES ARE NON-REFUNDABLE

Name________________________________________________________ Date of Birth __________________ State/Country of Birth_____________________

(Last)

(First)

(Middle)

(If born outside of US provide documentation)

(Please print full name as it appears on your driver license or state issued ID card)

Previously used Name(S)(Maiden, etc.)_______________________________________________Social Security Number_____________________________

Physical Address________________________________________________________________________________________________________________

(Street)

(City)

(County)

(State)

(Zip)

Mailing Address (if different from street address)____________________________________________________________________________________ __

Home Phone# _________________________Alt Phone #___________________________Driver Lic # _________________________________St. _____

Height _______________Weight _______________Eye Color _______________Hair Color _______________Sex ___________Race__________________

What is your Citizenship? _____________________If born outside of US, include Alien Registration # or INS Registration # ___________________________

ALL APPLICANTS: Please answer “Yes” or “No” to all questions below. A complete criminal background check will be conducted including

expunged and juvenile court records. If you answer “Yes” to any question, attach documentation explaining your answer.

☐ Yes

☐ No Have you ever been convicted of a felony?

☐ Yes

☐ No Have you ever been convicted of a crime of violence?

☐ Yes

☐ No Have you ever been convicted of an offense involving the use of alcohol? (i.e. DUI/DWI, alcohol related reckless, unlawful use of alcohol, etc.)

☐ Yes

☐ No Have you ever been convicted of the unlawful use of narcotics or other controlled substances?

☐ Yes

☐ No Have you ever been convicted of any offense involving moral turpitude? (i.e., theft, criminal mischief, sex crimes, etc.)

☐ Yes

☐ No Have you ever been convicted of offense involving domestic violence?

☐ Yes

☐ No Have you ever been adjudicated as mentally incompetent?

☐ Yes

☐ No Are you currently subject to a court sanctioned protective order?

☐ Yes

☐ No Have you ever been dishonorably discharged from the armed forces?

NEW APPLICANTS: A department approved firearms instructor must complete the following certification information:

The instructor’s stamp goes in this box

The applicant, ________________________________________ has met the criteria

established by the Utah Department of Public Safety and Utah Code Ann. § 53-5-

704(8). I certify this to be true and correct to the best of my knowledge and belief.

Instructor

Signature________________________________________________________

Training Date_________________________________________________

Month

Day

Year

ALL APPLICANTS: Please read and sign the statement below:

I understand that it is a class B misdemeanor to knowingly and willfully provide false information on a concealed firearm permit application and may result in the

denial of a permit pursuant to Utah Code Ann. § 53-5-704(15). I hereby declare under criminal penalty of the State of Utah that the information contained on this

application is true and correct.

Executed on: _____________________ at ___________

(Date)

(Time)

____________________________________

(Signature)

☐

METHOD OF PAYMENT (CHECK APPROPRIATE BOX)

Payment enclosed (check or money order only)

Credit Card

Credit Card payment must include 3 digit control number found on back of the credit card. There is a $20.00 service charge for any returned check.

Credit Card Signature_____________________________________________ Zip Code Associated with Credit Card ___________________