Norwalk Police Department

Temporarv State Pistol Permit Application and Instructions for Norwalk Residents

Records Division One Monroe Street Norwalk, CT 06854 (203) 8s4-300e

Dear Applicant:

You MUST be a bona fide permanent resident of the Citv of Norwalk to be eligible to apply. Non-resident property/business owners are not eligible. You must be 2l years old at the time you submit your application.

The State of Connecticut has implemented a Mandatory Online Pre-Enrollment procedure for fingerprint criminal history checks through the Connecticut Criminal History Request System (CCHRS) in which you must submit your information and pay the State and Federal fees online and then receive an Appli cant Transaction Number (ATN). Please follow the following Steps to be fingerprinted and submit an application for a temporary Pistol Permit.

STEP # 1 - Online Pre-Enrollment with the State of Connecticut:

L. Go to https://ct.flexcheck.us.idemia.io/cchrspreenroll (this link will also be on the Norwalk Police website) 2. Enter the Service Code E91E-8915 (designated only for Norwalk residents applying for a Pistol permit)

3. Enter your required information and pay the State $75 and FBI $13.25 fees (no longer collected by the police)

4. Print out Applicant Transaction Number (ATN) - you must have this number at fingerprinting. You cannot be fingerprinted without this Applicant Transaction Number.

STEP # 2 - Schedule Fineerprint Appointment Online.

ALL FINGERPRINTING IS NOW BY ONLINE APPOTNTMENT ONLY ! - NO WALK-INS WILL BE ACCEPTED.

1. To make a fingerprint appointment you can:

A: Go to the Norwalk Police website under the FAQs -'oHow do I Obtain a Pistol Permit" link and click on ooFingerprinting Online Scheduling" and choose a date and time slot. OR

B: type o6Norwalk Online Appointment Hub" into your internet browser and choose the calendar for 66All Fingerprinting Services" OR

C : Got to www.norwalkct.org/fingerprinting Fingerprinting Hours :

TUESDAY: 9:00 am - 12:00 pm & 1:30 pm - 4:00 pm WEDNESDAY: 9:00 am - 12:00 pm & 1:30 pm - 4:00 pm.

STEP # 3 - Items vou MIIST have at vour fingerprint appointment.

**Below is a check-off list of the items that you MUST bring with you for your fingerprint appointment. Failure to have any of the items listed will make your application incomplete and you will NOT be fingerprinted. Make sure you have each Item Number.

1. FULLY COMPLETED APPLTCATION: On a State of Connecticut Pistol Permit Application Form DPS-799-C (revised 3/03/21). Outdated forms will not be accepted. Check off the box for "60 Day Temporary State Pistol Permit" on page 1. All Questions must be answered.

2. NOTARIZED APPLICATION: Have the application notarized prior to your arrival. We do not notarize applications.

3. APPLTCANT TRANSACTION NUMBER (ATN) Must bring a print out of the Applicant Transaction Number (ATN) that you were issued at the completion of the online pre- Enrollment. You CANNOT be fingerprinted without this number. A. BASTC PISTOL SAFETY COURSE CERTIFICATE: An original Certificate of Completion for a course approved by the Commissioner of Public Safety in the safety and use of pistols and . **If you are submitting a NRA certificate that has been issued after May of 2016, they must be the new NRA approved form with ooHome Level I - 4 completion. '(**The NRA's Safety Courseo' and o'First Steps Pistol Orientation Program" are NOT accepted.

5. PHOTO: One (1) passport size color photo of yourself to attach to application.

6. PAYMENT:

Norwalk Police Fee : $70 (fingerprinting and background)

Pavment Methods: CASH or DEBIT/CREDIT CARD or MONEY ORDER- payable to o'@".

7. VALID PHOTO IDENTIFICATION: Proof of your identity and Norwalk Residency. - State of Connecticut Driver License; OR - State of CT Photo Identilication Card

Must show a Norwalk address 'r**Change License and Registration with CT DMV prior to fingerprint appointment if necessary. - Out of State Licenses NOT accepted.

8. PROOF of U.S. CITIZENSHIP or Lesallv in the U.S. You Must Bring One of the Following: Your United States Birth Certificate; OR Your Valid United States PassPort; OR Your Valid United States Permanent Resident Card

B) Non-Immierant Alien in the United States legallv: 1 - Visa or l-94 form (vatid) 2 - Exceptions under 18 USC 922(y\(2) - Admitted to U.S. for or has a valid hunting license. - Or received a waiver for the LJ.S. Attorney General.

9. The Temporary Pistol Permit is valid for only 60 days from the date it is signed. You must then convert the Temporary Pistol Permit to a State Permit with the Connecticut State Police and book an appointment on their website.

10. WARNING: You must list all applicable arrests and convictions from any State or Jurisdiction in the Criminal History Section on page 3 of the application.

Failing to provide accurate and complete information may result in the violation of Connecticut General Statute 53a-157b - False Statement. This may lead to an arrest warrant for the omission of disqualifying arrests and convictions.

11. A conviction may consist of a variety of dispositions such as: being found guilty at trial or pleading guilty to lesser charges. You may serve jail time or receive suspended jail time. You may have received suspended jail time and paid a fine. Received Probation or a Conditional Discharge. Just because you didn't go to jail does not mean you were not convicted of a crime. If not sure, list them, it is your responsibility.

12. The CT Judicial website only contains conviction information that goes back L0 years from the current date. If you are not sure of your conviction status, you can go to 66CRIMINAL www.ct.sov/dps and download the HISTORY RECORD REQUEST FORM" and follow the instructions to get your criminal record prior to filling out the pistol permit application.

Any Questions contact:

Lt. Art Weisgerber 203-854-3164 (best option due to availability)

Revised 712612021 Lt. Weisgerber NORWALK POLICE DEPT.

Connecticut Criminal History Request System Fingerprint Service Code Form

Service Name: TEMPORARY PISTOL PERMIT

To register for your fingerprints to be taken, please visit https://ct.flexcheck.us.idemia.iolcchrsoreenroll and enter the following Service Code: E91E-8915

Service Code is unique to your hiring/licensing agency. Do not use this code for onother purpose.

After entering the Service Code, confirm the Fingerprint Reason by selecting the "Yes - This information looks Correct" option. Complete the Pre-Enrollment information as completely as possible. All fields in bold font/blue highlight are mandatory to move forward with the process. After filling out all applicable fields, move to the next section by selecting the "submit Pre-Enrollment" button at the bottom of the screen. After completing the pre-enrollment steps, a confirmation screen will appear confirming registration is complete, including your Applicant Tracking Number. This Trackins Number will need to be taken to vour fingerprinting session. lt will also be sent to the e-mail address vou providg{.4llrins registration.

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1 -THE FORM ON THE LEFT IS WHAT YOU WLL SEE ONCE YOU SUCCESSFULLY COMPLETE TH E PRE-EN ROLLEMT.

2 -THE FORM ON THE RIGHT IS THE PRINTED APPLICANT TRANSACTION NUMBER (ATN) THAT YOU MUST PRESENT AT YOUR FINGERPRINT APPOINTMENT.

3 - YOU CANNOT BE FINGERPRINTED WITHOUT A TRANSACTION NUMBER! STATE OF CONI{ECTICUT DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION DIVISION OF STATE POLICE Special Licensing and

PISTOL PE RMIT/ELIGIBI LITY CE RTI FICATE AP PLICATION fo C.G.S. .S$ 29-28 et s 29-36 et. and 53a-217 et. Before compteting this apptication, it rs suggesfed that you review the Connecticut General Sfafufes peftaining to firearms. These can be accessed on the lnternet at www.cqa.ct.qov or through your local library. Type of Permit Reque$qd: Check Box: I OO Oay Temporary State Pistol Permit ! Non-Resident State Pistol Permit X Eliginitity Certificate to Purchase Pistols or Revolvers E ftigiuitity Certificate to Purchase Long Guns_ lnstructions: lnstructions for Eligibility lnstructions for Non-Resident Certificates to Purchase Pistols lnstructions for State Pistol Permits: State Pistol Permits: or Revolvers and/or Eligibility Certificates to Purchase Long : **CALL 1. Complete this form (DPS-799-C) and submit to DESPP FOR PACKET** Complete this form and submit in appropriate local authority (local police, resident You must hold a valid permit or person at DESPP Headquarters, state trooper or first select person, as applicable) license to carry a pistol or Division of State Police, located at along with all of the following: issued by a recognized United Sfates 1111 Country Club Road, jurisdiction. Middletown, Connecticut along with . Firearms Safety & Use Course Certificate; the below; . $70.00, fee, payable to the local authority; Complete this form and submit to and DESPP, Division of State Police, pistol . Firearms Safety & Use Course . Proof you are legally and lawfully in the permit location along with all of the Certificate; United States (e.9., certified copy of birth following: . $35.00 fee, payable to certificate, U.S. passport or documentation Treasurer, State of Completed State of CT and Federal issued by l.C,E.). Connecticut; fingerprint card with $75.00 fee and . Application for a State Eligibility 2. Submit fingerprints for a criminal history check $13.25 fee, payable to Treasurer, Certificate for a Pistol or through a law enforcement agency State of Connecticut for criminal IIt Ct Ct Revolver or for Long Guns history background checks; C, on lLrre t*l*iln'ort (DPS-164-C); ntle4e- fre- Firearms Safety & Use Course . Proof you are legally and t,u.-lk $k+< CT Pru*^ Certificate; lawfully in the United States "( $70.00 fee, payable to Treasurer, (e.g., certified copy of birth 3. Upon approval, the local authority will issue a State of Connecticut; certificate, U.S. passport or Terpporary State Permit to Carry Pistols and Completed Application for State (DPS-11-C), days. documentation issued by Revolvers effective for 60 Permit to Carry Pistols and Revolvers l.C.E.);and form (DPS-46-C); 4. Within the 60 day period, go to a DESPP, . Proof of valid state issued photo permit Completed DPS-129-C signed and Division of State Police, pistol location and identification card. submit the following: notarized and 2x2 color photograph (passport style); Submit fingerprints for a criminal . The Temporary State Permit to Carry Pistols Copy of the permit or license to carry history check through a law (DPS-11-C) issued by the and Revolvers a pistol or revolver issued to you by a enforcement agency. Fees include a localauthority; recognized United States jurisdiction; $75.00 fee and a $13.25 fee, payable completed Application for State Permit to ' A Proof you are legally and lawfully in at the agency where the prints are Carry Pistols and Revolvers (DPS-46-C); the United States (e.9., certified copy taken. Fees must be paid by separate . fee, payable to Treasurer, State of $70.00 of birth certiflcate, U.S. passport or checks. Connecticut; _ documentation issued by LC.E.);and . Proof you are legally and laMully in the Proof of valid state issued photo Upon approval, your photograph will United States (e.9., certified copy of birth identification card. be taken at DESPP and you will be certificate, U.S. passport or documentation issued an eligibility certificate. issued by l.C.E.);and Out of State Pistol Permit lnformation: . Proof of valid state issued photo identification State of lssue: card. Expiration Date: 5. Upon approval, your photograph will be taken at DESPP and you willbe issued a stafe pistolpermit. Permit Number:

For Department of Emergency Services and Public Protection (DESPP), Division of State Police, pistol permit locations, access www.ct.qov/despp and follow the link to the Special Licensing and Firearms Unit or call (860) 685-8290. Note: All payments must be made with separate checks.

DPS-799-C (Rev. 03/03/2 I ) A n Affirm ativ e A c ti o n/E q u a I E mp I oy m e nt Op p o rt u n ity E mp lo y e r Page 1 of4 STATE OT CONIT{ECTICI T DEPARTMENT OF EMERGE}ICY SERITCES AND PIIBLIC PROTECTION DI\iIISION Of STATE POLICE

Contact / ldentifying lnformation: Name of Applicant Tt]TNTtrITTIn il il[ ,EI Last Suffix nn il n First Middle lnitial Eovide all ottrer namis by which you have been known (Maiden name, Aliases, Nicknames, etc.) (Attach additional sheet(s), if necessary)

Date of Birth Sex Height Weight Eye Color nn/nn/nfln [r lrrlr fx Irt. [Irn. lllr-u' fI Brown tr giue n Btacr Month/DaylYear n Green n Gray I Hazel Race Hair Golor [whit" fAmerican lndianlAlaskan Native [AsianlPacific lslander [ tsrown n Black n Blonde n nea l-lgtacr l-lunkno*n ECItrer Eeray nWhite neato Socia! Security Number (optional, hutwill help Inrnntrr nn p rcve nt mi si dentilicati o n) City/Town State ru[iltr-IuItr Country of Citizenship Alien Reg. Number (lf applicable) TtrItrDtrNtrNETtrTNTTTtr[tr[] r--lrftT tEntrt]I[n nesiCential Address {List sfeet address. Post office box numheqqlq !q$!geE!e!lg|- NNtrTf TIITITtrTNNNTNN[t]NNTtrTNTTTTtril Number/Sfeet t! ll t-l It lt I II TN, In nnn Citv/Town State Zip Code Lirst Residential Addresses for the Last 7 Years (Attach additional sheet(s), if necessary) .Any subsequent changes of address must be reported within 48 hours to the Special Licensing and Firearms Unit 1.

2 different from current residential address

Number/Street llilllil il nrfn, trn trTNII.ilTTN State Zip Code Home Telephone llumber Motor Vehicle Operator's Llcense Numher (trTN) trTN-TtrXN lrn[tr[rrnnrrrnnnf rl Area Code State of lssue Afternate([xn)nItr-rIxn Telephone l,lumber Area Code Emplovment History: List Employers for the Last 7 Years (Provide employer's name, address and telephone number) (Attach additional sheet(s), if necessary) 1.

2. Permit or Eligibility Certificate History: Have you had a firearms permit, permit application or eligibility certificate of any kind from ANY iurisdiction in the United States denied, suspended or revoked? nNO IIYES lf "YES,' provide:

1. ldentifu the iurisdiction which issued the denial, suspension or rcvocation: 2. Date of denial, suspension or revocation: 3. The reason for the denial, suspension or revocation:

Dp9799-C (Rev. 03/03/21 ,4n -tfflnnatite acdon{Equal EmplE-rrreilt Apportai$, EtnploT,er Page 2 of4 STATE OF CONNECTICUT I}trPARTMENT OF EMERGENCY SERVICES ANI' PUBLIC PROTECTION DTVISION OF STATE POLICE Medical Hiqtory:

Have you been confined in a hospitalfor mental illness in the past sixty (60) months by order of a Probate Gourt? nNO ilVfS lf 'YES," explain: (Attach additional sheet(s), if necessary)

Have you been discharged from custody within the past twenty years after having been found not guilty of a crime by reason of a mental disease or defect? trttO nyES lf "YES," explain: (Attach additional sheet(s), if necessary)

Have you been voluntarily admitted to a hospilal for mental illness within the past six (6) months for reasons other than solely for alcohol or drug dependencee INo ilYES lf "YES,. explain: (Attach additional sheet(s), if necessary)

Notice: DESPP herein notifies the applicant that, pursuant fo C.G.S. $$ 29-28 through 29-38b, DESPP will be notified by the Department of Mental Health and Addiction Serylces if the applicanf has been confined to a hospital for psychiatric disabitities within the preceding sixty (60) months by order of Probate Court, or if the applicant has been voluntarily admitted to a hospitalfor menial itlness within fhe pasf slx (6) rnonths for reasons other tha Criminal History: Enyjurisdiction?trt.tonYESlf"YES,"listallarrests,indicating charges, locations, dates of arrest and dispositions. (Attach additional sheet(s), if necessary)

ItJotrce; You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuantto C.G.S. $S46b-146, 54-76o, or 54-142a.|f your criminal records have been erased pursuant to one of these statutes, you may swear under oath trat you have never been arrested. Criminal records that may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. 46b-146), an adjudication as a youthful offender (C.G.S. 54-76o), a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, or a conviction for which the person received an absolute pardon (C.G.S. 54- 142a).

With regard to criminal history information arising from jurisdictions other than the State of Connecticut: You are not required to diselose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to the law of the other iurisdiction. Additionally, you are not required to disclose the existence of an arrest arising from another jurisdiction if you are permitted under the law of that jurisdiction to swear under oaih that you have never been arrested.

Have you ever been CONMCTED under the laws of this state, federal law or the laws of another iurisdiction? f ffO [VeS lf 'YES,' list all convictions, include charges, location, date of arrest, and disposition. (Atiach additional sheet(s), if necessary)

Are you currently on probation, parole, work release, in an alcohol and/or drug treatment program or other pre-trial diversionary program or currently released on personal recognizance, a written promise to appear or a bail bond for a pending court case? DNO f,yfS ff "YES," explain. (Attach additional sheet(s), if necessary)

Within the past five (5) years, have you been the subiect of a Protective Order or Restraining Order issued by a court in a case involving the use, attempted use or threatened use of physical force against another person, regardless of the outcome or result of any related criminal case? ENO IyeS

lf "YES,' which court issued the order?

Military History:

WereyoueveramemtleroftheArmedForcesoftheUnitedStates? nNO IYES(lfyes,pleaseincludeacopyofyourDD-214)

Were you ever discharged from the Armed Forses of the United States with a less than Honorable Discharge? nNO f]YES

DPS,799-C (Ret 03/03/21) AnAlfintalix /EqualEntploTmtent Apportwi$'Empl.oyer Page 3 of4 STATE OF CONl.lECTICtrf I}EPARTMENT OF EMERGENCY SERVICES AND PLTBLIC PROTECTIOI{ DTV]ISION OF STATE POLICE

Proof of Training:

"A#ach a cfrpy af the letter or wftificate affesfiing that you have complefed a course in the safety and use of pislols and reyolyers or iong guns (as appropiate, depending upon wh"tch permit or certificate you are requesting), signed by the inslructor of the course. lnstruc'tor: (Check applicable box)

[National Rifle Association [Departrnent of Energy and Environmental Protection (DEEFI Iother:

State lnstructor's Name and lD Number:

Declaration: n-wnichldonotbelievetobetrueandwhichisintendedtomisleadapublic servant in the performance of his or her official function, is punishable by law (See C.G"S. $ 53a-157b). I further understand that any statement in this application that is determined to be false or inaccurate shall constitute grounds for ihe denial of such application. lf approved before the facts are known, such approval shall be void if based on a false or inaccurate statement. My signature below attests to the accuracy, completeness and to the truth of all information supplied on this application:

I declare, under the penalties of false statement, that the answers to the above are true and correct.

Date Signed

STATE OF

Print Name COUNTY OF

Subscribed and swom to before me this day of 2A

- Name: Notary Public My Commission Expires: Commissioner of Superior Court

NOTICE: Appeal Process for Permits

ln the event that your application for pistol permit or eligibility certificate is denied or revoked, you may notify the Board of Firearms Permit Examiners, at 165 CapltolAve., Suite 1070, l-Nartford, CT 06106. Telephone: (860) 256-2947, in writing, within ninety {90) days, in order to begin your appeal process. At a hearing before the Board, you may request that your application be reconsidered or that your permit or eligibility certificate be reinstated.

furOtrtcialUse Only: Application Received: FBlSent: lJt'io l--lves Application Status: FBI Reply: Iruo IYes [Denied [tr/[tr/nntrtr ICE Response: Eruo trv*t lnpproved Month/DaylYear DMHAS: !t'to f,ves sPBt: trr.ro f]ves (Signature and title of issuing authority) Number:

DP$799-C (Rev, 03/03121) An Afffumatfue Action/Equal Enryloynent Opportwi4' Entpl.oyer Page 4 of4 STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND PUBLTC PROTECTION DIVISION OF STATE POLICE

lnstructions to Applicants

Pistol Permits - Pistol Permits - Pistol Permits - New Renewal In-Person Renewal by Mail

1. A valid Temporary State Permit to Carry 1. All pistol permits may be renewed in person 1. Out-of-state pistol permits may be renewed by mail. Pistols or Revolvers (DPS-11-C) must be at DESPP Headquarters ninety (90) days prior Effective 1OlO1l11, in-state renewals may also be completed presented in person at the Department of to expiration or up to ninety (90) days after by mail. Emergency Services and Public Protection expiration. No permit can be renewed after the (DESPP) Headquarters located at 11 11 ninety (90) day grace period following the 2. Confirm the accuracy of the information on DPS-129-C. lf Country Club Road, Middletown, expiration date. corrections are required, draw a single line through any Connecticut 06457-2389. incorrect information and write in the correct information. Sign 2. Confirm the accuracy of the information on the corrected form in the presence of a notary prior to 2. Proof of legal and lawful presence in the DPS-129-C. lf corrections are required, draw a mailing. United States is required. Acceptable forms single Iine through any incorrect information and of proof include a birth certificate, U.S. write in the correct information. Present the 3. Using transparent tape, attach a 2" x 2" color passport passport, or documentation of permanent corrected form to DESPP. photo, taken within the previous six (6) months, in the box residence from the U.S. Citizenship and provided. lmmigratlon Services. 3. Bring a $70.00 check or money order made payable to "Treasurer, State of Connecticut" or 4. lnclude a $70.00 check or money order made payable to 3. Payment of a $70-00 fee is required, exact cash payment. "Treasurer, State of Connecticut." Do not send cash. either by check or money order made payable to "Treasurer, State of Connecticut" 4. Provide proof of being legally and lawfully in 4. Proof of legal and lawful presence in the United States is or by exact cash payment. United States: U.S. Passport, Birth Certificate required. Acceptable forms of proof include a birth certificate, or Permanent Resident lD issued by LC.E. or U.S. passport, or documentation of permanent residence U.S. Citizenship and lmmigration Services. Do not 4. Your photograph and signature will be Natu ralization Certif icate ; from the taken at DESPP. NOTE: lf Place of Birth states, send originals. .VERIFIED', 5. lnclude a self-addressed, stamped #'10 envelope. you do not need to bring item # 4. 5. Your photograph and signature will be taken at DESPP.

Renewals for Armed Securitv Officers (Blue Cards/Class {} and Bail Enforcement Aqents (Gold Cards/Class2)

1. Follow the instructions above for Pistol Permits - Renewal ln-Person. 2. An additional check or money order for $62.00 is required, made payable to "Treasurer, State of Connecticut." 3. lnclude a self-addressed, stamped #10 envelope. 4. Armed Security Officers must submit a DPS-1030-C annually as proof of completion of the qualification refresher course.

Eliqibilitv Certificates (New & Renewals)

1. New applicants must complete the DPS-799-C and DPS-164-C, and sign it in the presence of an official when your photo is taken. 2. Submit an affidavit signed by an instructor certified by the State, the National Rifle Association, or the Department of Energy and Environmental Protection statingthattheapplicantsuccessfullycompletedasafetyortrainingcourseintheuseof pistolsorrevolversorlongguns, Suchstatementshall specifythat the instructor was so certified at the time that he taught the course, and shall include the full name of the applicant, and the date, location and duration of the course. 3. Submit fingerprints with two (2) separate checks or money orders to cover the federal processing fee of $13.25 and the state fee of $75.00, both made payableto"Treasurer,StateofConnecticut", fortherequiredcriminal backgroundchecks. 4. Submit an additional check or money order for $35.00 made payable to "Treasurer, State of Connecticut" for the processing of the Eligibility Certificate. lf you are appearing in person, exact cash payments will be accepted. 5. When applicable, criminal andior mental health records must be submitted per Connecticut General Statutes Section 29-369. 6. Renewal applicants must submit a DPS-129-C-2, with $35.00 fee made payable to "Treasurer, State of Connecticut'and documentation of legal and lavvful presence in the United States (see # 2 under "Pistol Permits NeW' for acceptable documents), if previously not verified. Do not mail cash. 7 . lnclude a self-addressed, stamped #10 envelope.

Ammunition Certificates (New & Renewals):

1 . New applicants must complete DESPP4l7-C, and sign it in the presence of an official when your photo is taken.

2. Submit check or money order for $35.00 made payable to "Treasurer, State of Connecticut' or exact cash payment, for the processing of the Ammunition Certificate.

When applicable, criminal and/or mental health records must be submitted per Connecticut General Statutes Section 29-369

Renewal applicants must submit a DPS-129-C-2 with $35.00 fee made payable to "Treasurer State of Connecticut." Do not mail cash.

SEE IMPORTANT NOT'CES - REYERSE S'DE

DPS-769-C (Ret. 1 2/28/2018) A n Affirmalive Actio n/E qual Employme nt Opportunily Employ er Page 1 ol 2 STATE OF COI\-NTCTICUT DEPARTI}TENT OF EMERGENCY SERVICES AN:D PLBLIC PROTECTION DI\'ISION OF STATE POLICE NOTICE will not be tssued or tre pursuant to C G s $S 29-28, 29-32,2S-36f 29-36l, and 1 B U S.C. S 922, app/ications covercd by these rrs0'r/Ctlons rercved if ?. You h*re a FELONY CONVICTIAN in any jurisdiction. 2. You have a MISDEMEANORCONV|CTION in Connecticut for one of the following crimes; After 10/01/1994 a. lllegal possession of controlled or hallucinogenic substances, as specifled under C G S. $ 21a-279 b Criminally negligent homiqde as specitied under C.G.S S 53a-58 c. Assaull in the thrrd degree as speci{ied under C.G S $ 53a-61 d. Assault of an etderly, blind. disabled or pregnant person or a person wrth intelledual disability in the third degree as spectfled under C.G.S $ 53+61a e. Threateninqintheseconddegreeasspecified underC.G S S53a-62 f. Reckless endangerment in the first degree as specified under C.G S $ 53a-63 S Unlawful restraint in the second degree as specilied under C.G.S S 53a-96 h Riot in the irst degree as specilied under C G S. $ 53a-1 75 i. Riot in the secord degree as specified under C G S $ 53a-1 76 j lnciting to riot as specifled under C G.S $ 53a-178 k Stalking in the second degree as speci{ied under C G.S. $ 53a-181d 3. youareanunlaw{ul userof oraddictedtoarrycontrolledsubstance(asdefinedintheControlled SubstancesAct(21 U.S.C.801, et. seq.}.

4. You were CO NVI,CTED ot a MISDEMEA NOR CRIME of DOMESTIC V IOLENC E' physical This means an offense that (1 ) is a misdemeanor under federal or stale laiv, and (2) has. as an element. the use or attempted use of force, or lhe lhreatened use of a deadly rrcapon, committed by a currenl or {ormer spouse, parent or guardian of the victim, or by a person wtth whom the victim shares a chitd in common, or by a person who is cohabitirs with or trho has cohabited with the viclim or spouse, parent, or guardian, or by any person similarly siluated lo a spouse, parent orgusrdian ot the viCim.

You nere diacharged from custody within the preceding 20 lrearc afrer having heen ioutd lfrT GIfiL7Y AF A CNtiE EV REASOTV OF [fEiI?'{[ I}TSEIISE OR I]EFECT pursuantto C.G.S. $ 53a'13-

6. you rerc CO TfiITUEO TO A ,fiSFfiAL for persons with psycfriatric disahilities {C.G.S. S t?a-495) within the preoeding sify {60} months by order of a FrobaE Cosrt.

7. you have been voluntarily admitted to a hospital ior persohB nith psychhtric disabilities, within the preoeding six (6) months for reasons other than Bol€ly ftr alcohol or drug dependene.

8. you are subilrt b a fiESfnAIArrItlG OFIIER or FROIECrTIE OFOER iesued hf 4 cou* after noiiEc and an oppoilunity to be heard has been prcvided to 1pu in a casc involving the uss, attemplsd use or threatened use of pttysical force against another pGIEon. g.G.S. s. You are the sublxt oil a court iasued risk !ilarrant to $€ic firearnp pursuafi to S 2g-30c(d).

10. You arc an IILEGAf ALlEltl in lhe United $tatea.

11. You are {IVOER tIre.AGE of21 yeae.

12. You ha\re renosnqed your United $tates EitiEnship.

13. You have been discharged from the Armed ForceE under a dishonorable condition.

14. You are prohibiled bUr ftderal hw, under I I U.B.C. S22 (gl or (nl.

Please nra1 in your reflewal or direct any questions regarding your slatus to DESPP Headquarters, Special Licensing and Firearrls Uni[ Iocated at 1 1 '11 Country Club Road, tritltOletor,nr, Cannecticut 06457-238S ar by telephone at {860) 685-8290. Hours of operation arq Monday through Friday 8:30 am - 4:'15 pm. Prease rcte att tocatiwe mfl !e cJpsed on State ard Fsdcrd lrdidys. Troop hcation may he closed during inclement lEather. No appoinweltts n€cessary.

Troop E - Montville l-3S5 N (between exits 6 & 9) lvtontuille, CT 06382, telephone 860-84&6539 - Tuesday, Wednesday. Friday, and Saturday B am - 12 pm and 12 30- 3.45 pm, Thursday 11 am -2 pm and 2 30 - 6 45 pm

Troop G - Bridgeport, 149 Prosped Streel, Bridgeport, Connecticut, 06604, telephone (203)696-2532 Tuesday,Wednesday,Friday,andSaturdayBam-12pmand1230-3.45pm,Thursday11am-2pmand2.30-6.45pm

Current schedules, hours and directions can be found at www.ct.oov,/despp - click on Special Licensing and Firearms Unit link

Ivhntal Health and Addiction Services itthe applicant has been conlined in a hospital for persons with psychiatric disabilities within the preceding sixty (60) months by order of Probate Court, or il the applicant has been voluntarily admitted to a hospital for persons with psychiatric disabilities within the preceding six (6) months for reasohs other than solely for alcohol or drug dependence. DESPP will use this informdion in order to fulfill its statutory under Connecticut General Statutes Sections 29-28, 29-36f.

DPS769-C (Rer 12t28i2018) An,{fr matfu e Aetia ruEqual E mpia^m e nt Opp o tt tmi4, E mploye r Page 2 ot 2