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APPLICATION FOR IOWA PERMIT TO CARRY …

Form WP5 – Published by Iowa Department of Public Safety Page 1 of 2 Form for use on or after 09/01/2017, Version 1 APPLICATION FOR IOWA PERMIT TO CARRY

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Text of APPLICATION FOR IOWA PERMIT TO CARRY …

Form WP5 Published by Iowa Department of Public Safety Page 1 of 2 Form for use on or after 09/01/2017, Version 1 APPLICATION FOR IOWA PERMIT TO CARRY WEAPONS TYPE OF PERMIT (check only one) Resident Nonprofessional Permit Peace Officer Permit Badge # Resident Professional Permit Reserve Peace Officer Permit Nonresident Professional Permit Correctional Officer Permit New Duplicate Renewal Permit Number Permit Expiration / / NOTE: Renewal applications must be received by the issuing officer within 30 days prior to the expiration of the applicant s current permit or within 30 days after expiration of the applicant s prior permit. Month Day Year NAME DATE OF BIRTH / / Last First Middle Month Day Year SEX (circle one) MALE FEMALE SOCIAL SECURITY NUMBER (optional) - - RESIDENCE ADDRESS Number Street Apt/Unit # City State Zip Code MAILING ADDRESS Same as residence address (skip mailing address section below) Different than residence address (complete mailing address section below) MAILING ADDRESS Number Street (or PO Box number) Apt/Unit # City State Zip Code COUNTRY OF CITIZENSHIP IF NOT CITIZEN: USCIS, ARN, OR I-94 ADMISSION NUMBER DRIVER S LICENSE OR NON-OPERATOR ID # DRIVER S LICENSE OR ID STATE OF ISSUANCE PRIMARY PHONE ALTERNATE PHONE (optional) ALIASES (list all other names ever used) TRAINING Handgun safety training course utilizing instructor certified by the National Rifle Association Armed forces small arms training (for those released or retired from Active Duty) - requires documentation of honorable discharge OR general discharge under honorable conditions (DD-214, DD-256, NGB-22, or similar) Handgun safety training course utilizing instructor certified by a state law enforcement agency Completion of law enforcement agency firearms training course that qualifies a peace officer to carry a firearm Armed forces small arms training (for those on Active Duty) - requires certificate of completion of basic training or similar Completion of a hunter education program approved by the Natural Resource Commission, if handgun safety training is noted on the certificate of completion Handgun safety training course for security guards, investigators, or special deputies if such course has been approved by the Iowa Department of Public Safety TRAINING EXEMPT Documentation that applicant holds or held an Iowa Permit to Carry Weapons issued on or after 01/01/2011 PERMIT ELIGIBILITY YES NO 1. Do you have charges pending for a felony? 2. Have you ever been convicted of a felony? 3. Have you ever been adjudicated delinquent for an offense that would be a felony if committed by an adult? 4. Have you ever been convicted of an offense involving a firearm or explosive that is classified as a misdemeanor AND is punishable by more than one year of imprisonment (such as an Iowa aggravated misdemeanor)? 5. Have you been convicted within the previous three years of an aggravated misdemeanor OR serious misdemeanor offense under Iowa Code Ch. 708, including but not limited to assault, intimidation, harassment, hazing, or stalking? 6. Have you ever been convicted of a misdemeanor crime of domestic violence? 7. Are you subject to a court order restraining you from harassing, stalking, or threatening your intimate partner, your child, or the child of your intimate partner? Form WP5 Published by Iowa Department of Public Safety Page 2 of 2 Form for use on or after 09/01/2017, Version 1 YES NO 8. Are you currently on probation for any offense? IF YES list the offense for which you are serving probation: 9. Are you a fugitive from justice? 10. Have you been dishonorably discharged from the Armed Forces? 11. Have you ever renounced your United States citizenship? 12. Have you unlawfully used any controlled substance in the previous 12 months? 13. Are you currently addicted to the use of alcohol? 14. Has a court, board, commission, or other lawful authority ever found you to be a danger to yourself or others? 15. Has a court, board, commission, or other lawful authority ever ordered you to receive treatment for mental health reasons, or for other reasons, such as drug abuse? 16. Has a court, board, commission, or other lawful authority ever found you to be incompetent to conduct your affairs? 17. Have you ever been found incompetent to stand trial for any offense? 18. Have you ever been found not guilty by reason of insanity for any offense? 19. Are you a citizen of the United States? COMMENTS Please provide relevant information about your responses to questions 1-19, such as having been granted a pardon, a special restoration of citizenship with firearms rights, an order granting Relief from Disabilities, or other relevant information: Authorization for Release I, (print name here) ________________________________________ _____, do hereby authorize a review and full disclosure of all records concerning myself, as required by Iowa Code Ch. 724 and Iowa Administrative Code 661 Ch 91, to any duly authorized agent of an Iowa sheriff or the Commissioner of the Iowa Department of Public Safety, whether the said records are of a public, private or confidential nature. I understand that any information obtained which is developed directly or indirectly, in whole or part, upon this release authorization will be considered in determining my qualification for obtaining a permit to carry weapons in the state of Iowa. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for providing accurate information, and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I understand that information provided on this form is generally confidential and may be released as provided by law. I certify that all information, including supporting documentation, provided in this application is true and correct, and I understand that I may be convicted of a class D felony pursuant to Iowa Code section (3) if I make what I know to be a false statement of material fact on this application or if I submit what I know to be any materially falsified or forged documentation in connection with this application. APPLICANT SIGNATURE DATE / / Month Day Year EMPLOYER AUTHORIZATION (required for Professional, Peace Officer, Reserve Officer, and Correctional Officer Permit only) EMPLOYER ADDRESS Number Street Suite # City State Zip Code NAME OF REPRESENTATIVE OF EMPLOYER Last First Middle EMPLOYMENT JUSTIFICATION ( peace officer, armed security, etc.) EMPLOYER SIGNATURE DATE / / Month Day Year ISSUING OFFICER (Iowa Sheriff or Commissioner of Public Safety) APPLICATION APPROVED DENIED DATE / / Month Day Year IF DENIED, REASON FOR DENIAL Sheriff of County, Iowa SIGNATURE Commissioner of the Iowa Department of Public Safety WRITTEN DENIAL NOTICE PROVIDED BY Personal Service Mail DATE OF NOTICE / / Month Day Year

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