Application for Firearms Purchaser Identification Card and/or Handgun Purchase Permit
This form is prescribed by the Superintendent for use by applicants for Firearms Purchaser I.D. Cards & Handgun Purchase Permits. Any alteration to this form is expressly forbidden.
Check Appropriate Block(s) |
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Initial Firearms Purchaser Identification Card |
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Change of name on Identification Card |
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Lost or Stolen Identification Card |
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List former name and attach copy of marriage license or court order |
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Mutilated Identification Card |
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Change of Address on Identification Card |
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Change of Sex on Identification Card |
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Application to Purchase a Handgun |
Quantity of Permits: |
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(1) NAME |
Last ( If female, include maiden) |
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First |
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Middle |
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(2) SOCIAL SECURITY NUMBER |
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- |
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- |
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(3) RESIDENCE ADDRESS |
Number & Street |
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City |
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State |
Zip |
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(4) HOME TELEPHONE |
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( |
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) |
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- |
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(5) DATE OF BIRTH |
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(6) AGE |
(7) PLACE OF BIRTH |
City, State, Country |
(8) DRIVER'S LICENSE NUMBER & STATE |
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(9) SEX |
RACE |
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HEIGHT |
WEIGHT |
HAIR |
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EYES |
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(10) DIST. PHYSICAL CHARACTERISTICS (Marks, Scars, Tattoos) |
(11) U.S. CITIZEN |
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Yes |
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No |
(12) NAME OF EMPLOYER |
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EMPLOYER'S ADDRESS & TELEPHONE |
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(13) OCCUPATION |
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(14) ADDRESS APPEARING ON FORMER FIREARMS IDENTIFICATION CARD (If Applicable) |
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(15) N.J. FIREARMS ID CARD/SBI NUMBER |
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(16) Have you ever been convicted of any domestic violence offense in any jurisdiction which involved the elements of (1) striking, kicking, shoving, or (2) |
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Yes |
purposely or attempting to or knowingly or recklessly causing bodily injury, or (3) negligently causing bodily injury to another with a deadly weapon? If yes, explain. |
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No |
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(17) Are you subject to any court order issued pursuant to Domestic Violence? If yes, explain. |
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Yes |
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No |
(18) Have you ever been adjudged a juvenile delinquent? If yes, list date(s), place(s), and offense(s). |
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Yes |
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No |
(19) Have you ever been convicted of a disorderly persons offense in New Jersey or any criminal offense in another jurisdiction where you could have been |
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Yes |
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sentenced up to six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and offense(s). |
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No |
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(20) Have you ever been convicted of a crime in New Jersey or a criminal offense in another jurisdiction where you could have been sentenced to more than |
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Yes |
six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and crime(s). |
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No |
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(21) Do you suffer from a |
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Yes |
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(22) If answer to question 21 is yes, does this make it unsafe for you to handle firearms? If not, explain. |
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Yes |
physical defect or disease? |
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No |
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No |
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(23) Are you an alcoholic? |
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Yes |
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(24) Have you ever been confined or committed to a mental institution or hospital for treatment or observation of a |
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Yes |
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No |
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mental or psychiatric condition on a temporary, interim, or permanent basis? If yes, give the name and location of the |
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No |
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institution or hospital and the date(s) of such confinement or commitment. |
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(25) Are you dependent |
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Yes |
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(26) Have you ever been attended, treated or observed by any doctor or psychiatrist or at any hospital or mental |
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Yes |
upon the use of a narcotic(s) |
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institution on an inpatient or outpatient basis for any mental or psychiatric condition? |
If yes, give the name and location |
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or other controlled |
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No |
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of the doctor, psychiatrist, hospital or institution and the date(s) of such occurrence. |
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No |
dangerous substance(s)? |
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(27) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, permit to carry a handgun or any other firearms license or |
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Yes |
application refused or revoked in New Jersey or any other state? If yes, explain. |
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No |
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(28) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of force and violence, either |
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Yes |
to overthrow the Government of the United States or of this State, or which seeks to deny others their rights under the Constitution of either the United States or |
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the State of New Jersey? If yes, list name and address of organization(s). |
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No |
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A.
B.
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APPLICANT: DO NOT WRITE BELOW THIS SPACE |
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I hereby certify that the answers given on this application are complete, true and correct |
A non-refundable fee of $5.00 for a Firearms Purchaser Identification Card (Initial |
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in every particular. I realize that if any of the foregoing answers made by me are false, I |
Firearms Purchaser ID card only) and/or $2.00 for each Permit to Purchase a Handgun, |
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am subject to punishment. |
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payable to the Superintendent of State Police or the Chief of Police in the municipality in |
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which you reside, must accompany this application. |
(30) |
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APPROVED |
IDENTIFICATION CARD/PERMIT NUMBER(S) |
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Signature of Applicant |
Date of Application |
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(The disclosure of my social security number is voluntary. Without this number, the processing of my |
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application may be delayed. This number is considered confidential.) |
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Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c. |
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Reason for Disapproval |
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DISAPPROVED |
A. CRIMINAL RECORD |
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APPLICANT: DO NOT WRITE BELOW THIS SPACE |
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B. PUBLIC HEALTH SAFETY AND WELFARE |
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This |
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Day of |
, 20 |
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C. MEDICAL, MENTAL OR ALCOHOLIC BACKGROUND |
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D. NARCOTICS/ DANGEROUS DRUG OFFENSE |
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GRANTED ON |
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APPEAL |
E. FALSIFICATION OF APPLICATION |
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Signature |
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Title |
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F. DOMESTIC VIOLENCE |
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G. OTHER (SPECIFY) |
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Department of Police |
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Municipal Code # |
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S.T.S. 033 (Rev. 09/09)