Get CT DPS-67-C 2013-2024

SIGNATURE OF SALESPERSON DEALER NAME IF APPLICABLE THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY THE SELLER AND PURCHASER DPS-67-C Rev. 06/30/13-Previous editions are obsolete An Affirmative Action/Equal Employment Opportunity Employer. APPLICATION TO PURCHASE A FIREARM C. G*S* 29-33 AND 29-37a WEAPON TYPE HANDGUN LONG GUN OTHER SALE AUTHORIZATION NUMBER S Name Last First Middle Date of Birth MM/DD/YYYY Address Include number street town state and zip Post Office boxes not accepted Sex Race Social Security Number optional Height Eye Color Country of Citizenship required ICE Number if applicable Pistol Permit Number/Eligibility Certificate Number required Police Identification Number Hair Color Expiration Date Agency Name Driver s License Number required State a* Have you been convicted of a felony Yes No b. Have you ever been convicted of a misdemeanor crime of domestic/family violence c* Are you the subject of an active restraining or protective order issued by a court after notice and an opportunity to be heard has been provided to you in a case involving the use attempted use or threatened use of physical force against another person by order of a Probate Court Yes No e. Have you been voluntarily admitted to a hospital for persons with psychiatric disabilities within the preceding six 6 months for reasons other than solely for alcohol or drug dependence f* Have you been discharged from custody within the preceding twenty 20 years after having been found not guilty of a crime by reason of mental disease or defect pursuant to Connecticut General Statutes Section 53a-13 h. Have you ever had an application to purchase a firearm denied in any other State If so Where When Reason for denial If yes check all that apply. Illegal possession of controlled or hallucinogenic substances C. G*S* 21a-279 c Criminally negligent homicide C. G*S* 53a-58 rd Assault in the 3 C. G*S* 53a-61 Assault of a victim 60 or older in the 3 C. G*S* 53a-61a nd Threatening 2 C. G*S* 53a-62 st Reckless endangerment 1 C. G*S* 53a-63 Unlawful restraint 2 C. G*S* 53a-96 Riot 1 C. G*S* 53a-175 Inciting to riot C. G*S* 53a-178 Stalking 2 C. G*S* 53a-181d Information provided on this application is subject to verification from sources including probate civil and criminal courts as well as governmental agencies pursuant to State and Federal Law e*g* P. A. 13-3 as amended by P. A. 13-220 P. A. 98-129 and 18 U*S*C. 922 as may be amended* I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS DOCUMENT IS A VIOLATION OF CONNECTICUT GENERAL STATUTES SECTIONS 29-34 AND/OR 29-37e AND CONSTITUTES A CLASS D FELONY OR IN SOME CASES A CLASS B FELONY. SIGNATURE OF PURCHASER DATE I UNDERSTAND THAT A PERSON WHO ANSWERS YES TO QUESTIONS A-G IS PROHIBITED FROM PURCHASING A FIREARM. THOSE APPLICANT S ANSWERING IN THE AFFIRMATIVE TO QUESTIONS H AND I MAY BE PROHIBITED UPON COMPLETION OF A BACKGROUND CHECK. APPLICATION TO PURCHASE A FIREARM C. G*S* 29-33 AND 29-37a WEAPON TYPE HANDGUN LONG GUN OTHER SALE AUTHORIZATION NUMBER S Name Last First Middle Date of Birth MM/DD/YYYY Address Include number street town state and zip Post Office boxes not accepted Sex Race Social Security Number optional Height Eye Color Country of Citizenship required ICE Number if applicable Pistol Permit Number/Eligibility Certificate Number required Police Identification Number Hair Color Expiration Date Agency Name Driver s License Number required State a* Have you been convicted of a felony Yes No b. Have you ever been convicted of a misdemeanor crime of domestic/family violence c* Are you the subject of an active restraining or protective order issued by a court after notice and an opportunity to be heard has been provided to you in a case involving the use attempted use or threatened use of physical force against another person by order of a Probate Court Yes No e. .