PISTOL PERMIT APPLICATION

Read the following carefully and provide complete and accurate information. It is a crime to make a false statement or report to law enforcement.
(Title 13A-10-109, Code of Alabama, 1975). A criminal history background check will be conducted on each applicant.

Name*

First NameMiddle NameLast Name

Other Names You Have Been Known By:*

Type Name Here

Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address:

Mailing Address

CityState / Province

Postal / Zip Code

Email*

example@example.com

Home Phone Number

Area CodePhone Number

Cell Number

Area CodePhone Number

Age*

Numbers Only

Date of Birth*

Example: 01/01/2000

Place of Birth:*

City / State

Are You A United States Citizen*

YESNO

Gender*

MALEFEMALE

Race:*

Height:*

Weight:*

Hair Color:*

Eye Color:*

Driver's License Number:*

Driver's License State of Issuance:*

Social Security Number:*

Employer:*

Employer's Phone Number*

Area CodePhone Number

Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PLEASE ANSWER YES/NO TO THE FOLLOWING QUESTIONS:

1. Have you ever had a pistol permit?*

YESNO

If you answered yes to question #1, indicate county of previous permit below

2. Have you ever had a pistol permit revoked or denied?*

YESNO

If you answered yes to question #2 indicate below what county revoked or denied your permit.

3. Have you ever been arrested for a crime of violence?*

YESNO

4. Have you ever been taken into custody by a law enforcement agency?*

YESNO

5. Have you ever been arrested or charged with a crime?*

YESNO

6. Are you currently under indictment?*

YESNO

7. Have you ever been treated for a mental illness?*

YESNO

8. Have you ever been treated for a substance abuse problem (Ex: alcohol, illegal drugs)?*

YESNO

9. Are you addicted to alcohol, prescription medication or any illegal drugs?*

YESNO

10. Are you on probation or under a restraining order from ANY court?*

YESNO

11. Are you awaiting trial as a defendant in any criminal case?*

YESNO

12. Have you been fond guilty but mentally ill in any criminal case?*

YESNO

13. Have you been found not guilty in a criminal case by reasons of insanity or mental disease or defect?*

YESNO

14. Have you been declared incompetent to stand trial in a criminal case?*

YESNO

15. Have you asserted a defense in a criminal case of not guilty by reason of insanity or mental disease or defect?*

YESNO

16. Have you been found not guilty by reason of lack of mental responsibility under the Uniform Code of Military Justice?*

YESNO

17. Have you required involuntary outpatient treatment in a psychiatric hospital or similar treatment facility based on a finding that you are an imminent danger to yourself or to others?*

YESNO

18. Have you required involuntary commitment to a psychiatric hospital or similar treatment facility for any reasons including drug use?*

YESNO

19. Have you been the subject of a prosecution or of a commitment or incompetency proceeding that could lead to a prohibition on the receipt or possession of a firearm under the laws of the State of Alabama or the United States?*

YESNO

If you answered YES to any of the above questions, please use the space below to provide dates and places of arrests, treatments, charges, agencies and dispositions.

I CERTIFY THAT MY ANSWERS ARE TRUE, CORRECT AND COMPLETE. I UNDERSTAND THIS APPLICATION WILL BE REJECTED IF ANY INFORMATION IS FOUND TO BE FALSE OR MISLEADING. USE YOUR MOUSE TO SIGN ON LINE BELOW.*

DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY

APPROVED:______ NOT APPROVED:______

AUTHORIZED SIGNATURE: ______________________________________________________

NCIC__________ACJIC__________NICS__________

TRANSACTION NUMBER:____________________________ OTHER:______________________________________________

HALE COUNTY SHERIFF'S OFFICE