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APPLICATION FOR A PENNSYLVANIA LICENSE TO …

sp 4-127 (10-2012) commonwealth of pennsylvania renewal county of_____ application for a pennsylvania license to carry firearms

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SP 4-127 (10-2012) COMMONWEALTH OF PENNSYLVANIA RENEWAL COUNTY OF______________________________ APPLICATION FOR A PENNSYLVANIA LICENSE TO CARRY FIREARMS FOR USE BY ISSUING AUTHORITY: PICS Temp App. No _____________ PICS Perm. App. No. ______________ Application Date _____________ License No. _________________ Temporary License Approval Date __________________ Permanent License Approval Date ___________________ Rejection Date ____________ Reason for Rejection _________________________________ Signature ____________________________________ APPLICANT INFORMATION TYPE/PRINT IN BLUE OR BLACK INK 1. LAST NAME 2. JR., ETC. 3. FIRST NAME4. MIDDLE NAME5. PHOTO ID/DRIVER LICENSE STATE7a. DATE OF BIRTH 7b. PLACE OF BIRTH 8. SOCIAL SECURITY NUMBER (Optional) 9. AGE10. SEX11. RACE12. HEIGHT 13. WEIGHT 14. HAIR COLOR15. EYE COLOR16. STREET ADDRESS 17. CITY18. STATE 19. ZIP CODE 20. HOME TELEPHONE NO. - - 21. EMPLOYER/BUSINESS NAME 22. WORK TELEPHONE NO. - - 23. OCCUPATION24. ADDRESS 25. CITY26. STATE27. ZIP CODE28. REASON FOR A LICENSE TO CARRY FIREARMS: SELF-DEFENSE EMPLOYMENT HUNTING/FISHING TARGET SHOOTING GUN COLLECTING OTHER __________________________29. TWO REFERENCES NOT FAMILY MEMBERS NAME ADDRESSTELEPHONE NO. - - NAME ADDRESSTELEPHONE NO. - - APPLICANTS ARE DETERMINED TO BE ELIGIBLE FOR A LICENSE TO CARRY FIREARMS BASED UPON CRITERIA SET FORTH WITHIN THE PENNSYLVANIA UNIFORM FIREARMS ACT (18 CHAPTER 61) 6105, DEALING WITH INDIVIDUALS NOT TO POSSESS FIREARMS AND 6109, DEALING WITH THE ISSUANCE OF A LICENSE TO CARRY FIREARMS. 30. DO YOU MEET ANY OF THE FOLLOWING PROHIBITING CRITERIA UNDER 18 6109(e)(1)? CHECK YES OR NO IN THE BOX BY EACH QUESTION: A. IS YOUR CHARACTER AND REPUTATION SUCH THAT YOU WOULD BE LIKELY TO ACT IN A MANNER DANGEROUS TO PUBLIC SAFETY? YES NOB. HAVE YOU EVER BEEN CONVICTED OF AN OFFENSE UNDER THE ACT OF APRIL 14, 1972 ( 233, NO. 64) KNOWN AS THE CONTROLLED SUBSTANCE, DRUG, DEVICE AND COSMETIC ACT (CSDDCA)? (AS PROVIDED IN 18 6109(e)(1)(II), ANY PENNSYLVANIA DRUG CONVICTION UNDER THE CSDDCA IS PROHIBITING FOR A LICENSE TO CARRY.) YES NOC. HAVE YOU EVER BEEN CONVICTED OF A CRIME ENUMERATED IN 6105(b), OR DO ANY OF THE CONDITIONS UNDER 6105(c) APPLY TO YOU? (READ INFORMATION ON BACK PRIOR TO ANSWERING) YES NOD. HAVE YOU EVER BEEN ADJUDICATED DELINQUENT FOR A CRIME ENUMERATED IN 6105 OR FOR AN OFFENSE UNDER THE CONTROLLED SUBSTANCE, DRUG, DEVICE AND COSMETIC ACT? YES NOE. HAVE YOU EVER BEEN INVOLUNTARILY COMMITTED TO A HOSPITAL/HEALTH CARE FACILITY FOR A MENTAL HEALTH CONDITION OR OTHER TREATMENT, OR ADJUDICATED INCOMPETENT/INCAPACITATED? YES NOF. ARE YOU AN INDIVIDUAL WHO IS A HABITUAL DRUNKARD, OR WHO IS ADDICTED TO OR AN UNLAWFUL USER OF MARIJUANA OR A STIMULANT, DEPRESSANT, OR NARCOTIC DRUG? YES NOG. ARE YOU NOW CHARGED WITH, OR HAVE YOU EVER BEEN CONVICTED OF A CRIME PUNISHABLE BY IMPRISONMENT FOR A TERM EXCEEDING ONE YEAR? THIS IS THE MAXIMUM SENTENCE YOU COULD HAVE RECEIVED, NOT THE ACTUAL SENTENCE YOU DID RECEIVE. (IT DOES NOT INCLUDE FEDERAL OR STATE OFFENSES PERTAINING TO ANTITRUST, UNFAIR TRADE PRACTICES, RESTRAINTS OF TRADE, OR REGULATION OF BUSINESS; OR STATE OFFENSES CLASSIFIED AS MISDEMEANORS AND PUNISHABLE BY A TERM OF IMPRISONMENT NOT EXCEEDING TWO YEARS.) YES NOH. HAVE YOU EVER RECEIVED A DISHONORABLE DISCHARGE FROM THE UNITED STATES ARMED FORCES? YES NOI. ARE YOU A FUGITIVE FROM JUSTICE? THIS DOES NOT APPLY TO MOVING OR NONMOVING SUMMARY OFFENSES UNDER TITLE 75 (RELATING TO MOTOR VEHICLES). YES NOJ. ARE YOU PROHIBITED FROM POSSESSING OR ACQUIRING A FIREARM UNDER THE STATUTES OF THE UNITED STATES? YES NO31. ARE YOU A UNITED STATES CITIZEN? IF NO, COUNTRY OF BIRTH___________________________________ ________ COUNTRY OF CITIZENSHIP_____________________________ _______ ALIEN REGISTRATION # OR I-94#______________________________ YES NO32. IF YOU ARE A RESIDENT OF ANOTHER STATE, DO YOU POSSESS A CURRENT LICENSE, PERMIT, OR SIMILAR DOCUMENT TO CARRY A FIREARM ISSUED BY THAT STATE? IF YES, ATTACH A PHOTOCOPY OF THE DOCUMENT TO THIS FORM. YES NO33. I have never been convicted of a crime that prohibits me from possessing or acquiring a firearm under Federal or State law. I am of sound mind and have never been committed to a mental institution or mental health care facility. I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties prescribed by law. I authorize the sheriff, or his designee, or, in the case of first class cities, the chief or head of the police department, or his designee, to inspect only those records or documents relevant to information required for this application. If I am issued a license and knowingly become ineligible to legally possess or acquire firearms, I will promptly notify the sheriff of the county in which I reside or, if I reside in a city of the first class, the chief of police of that city. This certification is made subject to both the penalties of 4904 of the Crimes Code, 18 , relating to unsworn falsifications to authorities and the Uniform Firearms Act. SIGNATURE - APPLICANT ________________________________________ _____________ DATE OF APPLICATION _________________________ Section 6105(a): Effective November 22, 1995, 18 6105(a) prohibits persons convicted of any of the following offenses under 18 from possessing, using, controlling, transferring, manufacturing, or obtaining a license to possess, use, control, transfer, or manufacture a firearm in the Commonwealth of Pennsylvania. A conviction includes a finding of guilty or the entering of a plea of guilty or nolo contendere, whether or not judgment has been imposed, as determined by the law of the jurisdiction in which the prosecution was held. The term does not include a conviction which has been expunged or overturned or for which an individual has been pardoned unless the pardon expressly provides that the individual may not possess or transport firearms. Section 6105(b) 908 Prohibited offensive weapons 911 Corrupt organizations 912 Possession of weapon on school property 2502 Murder 2503 Voluntary manslaughter 2504 Involuntary manslaughter, if the offense is based on the reckless use of a firearm 2702 Aggravated assault 2703 Assault by prisoner 2704 Assault by life prisoner Stalking 2716 Weapons of mass destruction 2901 Kidnapping 2902 Unlawful restraint 2910 Luring a child into a motor vehicle or structure 3121 Rape 3123 Involuntary deviate sexual intercourse 3125 Aggravated indecent assault 3301 Arson and related offenses 3302 Causing or risking catastrophe 3502 Burglary 3503 Criminal trespass, if the offense is graded a felony of the second degree or higher 3701 Robbery 3702 Robbery of motor vehicle 3921 Theft by unlawful taking or disposition, upon conviction of the second felony offense 3923 Theft by extortion, when the offense is accompanied by threats of violence 3925 Receiving stolen property, upon conviction of the second felony offense 4906 False reports to law enforcement authorities, if the fictitious report involved the theft of a firearm as provided in 4906(c)(2) 4912 Impersonating a public servant if the person is impersonating a law enforcement officer 4952 Intimidation of witnesses or victims 4953 Retaliation against witness, victim or party 5121 Escape 5122 Weapons or implements for escape 5501(3) Riot 5515 Prohibiting of paramilitary training 5516 Facsimile weapons of mass destruction Possession of firearm by minor 6301 Corruption of minors 6302 Sale or lease of weapons and explosives Any offense equivalent to any of the above-enumerated offenses under the prior laws of this Commonwealth or any offense equivalent to any of the above-enumerated offenses under the statutes of any other state or of the United States. Section 6105(c): Effective November 22, 1995, 18 6105(c) also prohibits the following persons from possessing, using, controlling, transferring, manufacturing, or obtaining a license to possess, use, control, transfer, or manufacture a firearm in the Commonwealth of Pennsylvania. ARE YOU A PERSON WHO: 1. is a fugitive from justice; or 2. has been convicted of an offense under the act of April 14, 1972 ( 233, No. 64), known as The Controlled Substance, Drug, Device and Cosmetic Act, or any equivalent Federal statute or equivalent statute of any other state, that may be punishable by a term of imprisonment exceeding two years; or 3. has been convicted of driving under the influence of alcohol or controlled substance as provided in 75 3802 (relating to driving under influence of alcohol or controlled substance) or the former 75 3731, on three or more separate occasions within a five-year period. For the purposes of this paragraph only, the prohibition of subsection 6105(a) shall only apply to transfers or purchases of firearms after the third conviction; or 4. has been adjudicated as an incompetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under section 302, 303, or 304 of the provisions of the act of July 9, 1976 ( 817, No. 143), known as the Mental Health Procedures Act; or 5. being an alien, is illegally or unlawfully in the United States; or 6. is the subject of an active protection from abuse order issued pursuant to 23 6108 (relating to relief), which order provided for the relinquishment of firearms during the period of time the order is in effect. This prohibition shall terminate upon the expiration or vacation of an active protection from abuse order or portion thereof relating to the relinquishment of firearms; or 7. was adjudicated delinquent by a court pursuant to 42 6341 (relating to adjudication) or under any equivalent Federal statute or statute of any other state as a result of conduct which if committed by an adult would constitute an offense under 18 2502, 2503, 2702, 2703, 2704, 2901, 3121, 3123, 3301, 3502, 3701, and 3923; or 8. was adjudicated delinquent by a court pursuant to 42 6341 or under any equivalent Federal statute or statute of any other state as a result of conduct which if committed by an adult would constitute an offense enumerated in 18 6105(b) with the exception of those crimes set forth in paragraph 7. This prohibition shall terminate 15 years after the last applicable delinquent adjudication or upon the person reaching the age of 30, whichever is earlier. 9. is prohibited from possessing or acquiring a firearm under 18 922(g)(9) (relating to unlawful acts) who has been convicted in any court of a misdemeanor crime of domestic violence by a person in any of the following relationships: (i) the current or former spouse, parent or guardian of the victim; (ii) a person with whom the victim shares a child in common; (iii) a person who cohabits with or has cohabited with the victim as a spouse, parent or guardian; or (iv) a person similarly situated to a spouse, parent, or guardian of the victim; then the relationship need not be an element of the offense to meet the requirements of this paragraph. PRIVACY ACT NOTICE Solicitation of this information is authorized under Title 18 6111. Disclosure of your social security number is voluntary. Your social security number, if provided, may be used to verify your identity and prevent misidentification. All information supplied, including your social security number, is confidential and not subject to public disclosure.

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