Application For Concealed Firearm Permit - State Of Utah (Page 2 of 2) in pdf

State of Utah

Department of Public Safety

APPLICATION FOR CONCEALED FIREARM PERMIT

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 have been answered. Be sure to provide all

supporting documents: one complete fingerprint card, one photo (with name on back), and photocopy of drivers license. Enclose the appropriate fee, $65.25,

in the form of cash, check, money order or credit card made payable to “Utah Bureau of Criminal Identification”. FEES ARE NON-REFUNDABLE.

Name__________________________________________________________Date of Birth __________________Place of Birth________________________

(Last)

(First)

(Middle)

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

Address_______________________________________________________________________________________________________________________

(Street)

(City)

(County)

(State)

(Zip)

Mailing Address (if different from street address)_______________________________________________________________________________________

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

Height _______________Weight _______________Eye Color _______________Hair Color _______________Sex ___________Race_________________

What is your Citizenship? __________________________________Alien Registration # or Naturalization # _______________________________________

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, supply alcohol to minor, 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 arrested for any offense involving domestic violence?

☐ Yes

☐ No

Have you ever been adjudicated as mentally incompetent?

☐ Yes

☐ No

Have you ever been involved in any incident in which you have used unlawful violence or threats of unlawful violence?

☐ 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 53-5-704(8) Utah Code

Annotated. I certify this to be true and correct to the best of my knowledge and belief.

Instructor

Signature________________________________________________________

Date____________________________________________________________

ALL APPLICANTS: Please read and sign the statement below. Your signature must be notarized to complete this form.

I,______________________________________________, hereby certify that the statements contained herein are true and correct to the best of my knowledge. I understand that if I

knowingly make any false statements herein, I am subject to the penalties prescribed by law. I do hereby authorize the release of any and all information in the possession of any

individual, law enforcement agency, firm, partnership, and public or private corporation, necessary to determine the validity and appropriateness of my application. In so doing, I release,

exonerate, and hold harmless, any such individual, law enforcement agency, firm, partnership, public or private corporation, the Utah Department of Public Safety, and the State of Utah,

from any claim or cause of action which may or could result from the release of this information. I further certify that I will adhere to Utah Code Ann. § 53-5-704, and that failure to

comply with these laws may result in the denial, suspension, or revocation of my concealed firearm permit.

Signature_________________________________________________________Date_____________________

Subscribed and sworn to this______________day of________________________________20______________

__________________________________________________

Notary Public

☐

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 Orders: