California Department of Justice STANDARD APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON (CCW) CIA 4012 (6199) California Department of Justice STANDARD APPLICATION for LICENSE TO CARRY A CONCEALED WEAPON (CCW) Authority California Penal Code (PC) sections 12050 through 12054. provide that a sheriff of a county or the chief or other head of a municipal police department of any city or city and county may issue a license to carry a pistol, revolver, or other firearm capable of being concealed upon the person (CCW license). PC section 1205 1 (a)(3)(A) requires the Attorney General to prescribe a statewide standard application form for a CCW license. Who Maybe Issued a License The licensing authority specified in PC section 12050(a)(1) (a sheriff or head of a municipal police department) may issue a license to persons who are of good moral character, who have completed a course of training, and where good cause exists for issuance of the CCW license. All applicants for a CCW will be fingerprinted and state records will be checked to determine if they are in a prohibiting class. Attachments 1 2 and 3 (following page 14 of this application) list all categories that would cause a person to be in a class prohibiting them from possessing firearms and being granted a CCW license. These attachments are updated annually to reflect new legislation and other changes in the law. Format of CCW License A CCW license may be issued in either of the following formats: A license to carry concealed, a pistol, revolver, or other firearm capable of being concealed upon the person. Where the population of the county is less than 200,000 persons according to the most recent federal decennial census, a license to carry loaded and exposed in that county a pistol, revolver, or other firearm capable of being concealed upon the person. Training Required PC section 12050(a)(1)(B) and (E) specifies that new license applicants must complete a course of training. The training may consist of any course acceptable to the licensing authority. The licensing authority may require either a course not to exceed 16 hours which includes instruction on at least firearms safety and the law regarding the permissible use of a firearm or a community college course not to exceed 24 hours certified by the Commission on Peace Officer Standards and Training. If the licensing authority requires the community college course, it must be uniformly required for all CCW license applicants. The licensing authority may also require annual qualification on the weapon(s) during the term for which the CCW license is granted. For license renewal applicants, the course of training may be any course acceptable to the licensing authority, shall be no less than four hours in length, and shall include instruction on at least firearm safety and the law regarding permissible use of a firearm. State of California, Department of Justice Standard Application for CCW License Psychological Testing In addition to licensing requirements as specified by the licensing authority, may require psychological testing on the initial application. If required, the applicant shall be referred to a licensed psychologist used by the licensing authority for the psychological testing of its own employees. Any fees charged will be the responsibility of the applicant and such fees shall not exceed $150.00 for an initial test. Additional psychological testing of an applicant seeking license renewal shall be required only if there is compelling evidence to indicate that a test is necessary (PC section 12054(c)). Completing the Application The Answering all the questions on this standard application does not guarantee the issua:n t1censing determination whether or not to issue the license is the prerogative of the licensing au oi y authority, in addition to using the state standard application form, will have a written policy summarizing what they require pursuant to PC section 12050(a)(1)(A) and (B). Prior to issuing a COW, the statutes require proof that: • The applicant is of good moral character, Good cause exists to issue the CCW license, The applicant meets residence requirements, and The course of training prescribed by the licensing authority has been completed. The application on the following pages sets forth standardized questions to be used by the COW licensing authority to determine whether a CCW license shall be issued. The applicant shall not be required to complete any additional application or form for a COW license, or to provide any information other than that necessary to complete this standard application form except to clarify or interpret information provided herein (PC section 1205 I (a)(3)(C)). The applicant will certify that all answers provided are true and correct to the best of their knowledge and belief under penalty of perjury. The applicant will also acknowledge that information disclosed on this application may be subject to public disclosure: tmrtantlttruct,ons • Fill out read, andign Sections 1 through 5, as directed. Use additional pages if more space is required. • Sections 6, 7, and 8 must be completed in the presence of an officiaI1f the licensing • Review Section 7 and be prepared to answer these questions orally. Do not write anything in Section 7 unless specifically directed to do so by the licensing agency.' Section'I - AppllcantPersonal Information ------------------------------------------------3 Section 2- Applicant Clearance Questions ------------------------------------------------.3 Section 3-DescriptionofWeapon(s) ----------------------------------------------------- 5 Section 4 CGW Ljcnse Conditions and Restrictions 6 Section 5 -Applicable California Penal Code Sections ----------------------------------------7 Section 6- Agreement to Restrictions and to Hold Harmless -------- - -------------------------10 Section 7- Investigator's Interview Notes ------------------------------------------------ 11 Section 8-Certification and Release of Information ---------------------------------------- 14 - - . - Attachment -California Prohibiting Categories for aCCW License ---------------------------16 Attachment 2-California Prohibiting Misdemeanors ----------------------------------------17 Attachment 3 Federal Prohibiting Categories for Possessing Firearms-------------------------19 - -2- State of California, Department of Justice Standard Application for CCW License Official Use Only -Type of Permit Requested ()Standard ()Judge ()Reserve Officer Q 90 Day I understand that I am obligated to be complete and truthful in providing information on this application. I understand that all of the information disclosed by me in this application may be subject to public disclosure. dn Applicant a Siature Date Witness Signature I Badge Number Date Name: M Last If Applicable, Maiden Name or Other Name(s) Used: City and County of Residence: S0 Middle First r 17VIQQ Country of Citizenship: Jr_.__ Place of Birth Date of Birth: 1. Cotinty Color Hth: Do you now have, or have you ever had a license to carry a concealed weapon (CCW)? (If yes, please indicate below. Use additional pages if necessary.) Yes No Issuing Agency2-/ /t4i<_ 2. Color Eyes: Weight: 4 - City Height: S. 54 Issue Date 7(113 /o5' CC\IW Have yo,ever applied for and been denied a license to carry a concealed weapon? No 1Yes ______ (If yes, give agency name, date and reason for denial.) -3- state/ 4.State of California, Department of Justice Standard Application for CCW License 3. held and subsequently renounced your United States citizenship? Have you NoL-'Yes_______ (If yes, explain): 4. If you served with the Armed Forces, were you ever convicted of any charges or was your discharge other than honorable? No Are you now, or have you been, a party to a lawsuit in the last rive years? 5. No Yes (Ifves. exoIain: Are you now, or havyou been, under a restraining order(s) from any court? 6. (If yes, explain): NoYes fc Ac,!,2f. ,qq 5, 5fr2lL& &b L 7J2, -O fl IZ Ao Z - 6"rt- 7. (If yes, explain): Yes ______ op /y Are you on probation or parole from any state for conviction of any offense including traffic? No '"Yes _______ (If yes, explain): -4- State of Cal iforni a, Department of Justice Standard Application for CCW License The licensee is responsible for all liability for, injury to, or death of any person, or damage to any property which may result through any act or omission of either the licensee or the agency that issued the license. In the event any claim, suit, or action is brought against the agency that issued the license, its chief officer or any of its employees, by reason of, or in connectioh with any such act or omission, the licensee shall defend, indemnify, and hold harmless the agency that issued the license, its chief officer or any of its employees from such claim, suit, or action. The licensee authorizes the licensing agency to investigate, as they deem necessary, the licensee's record and character to ascertain any and all information which may concern his/her qualifications and justification to be issued a license to carry a concealed weapon and release said agency of any and all liability arising out of such investigation. While exercising the privileges granted to the licensee under the terms of this license, the licensee shall not, when carrying a concealed weapon: u Consume any alcoholic beverage. • Be in a place having a primary purpose of dispensing alcoholic' beverages for on-site consumption. u Be under the influence of any medication or drug, whether prescribed or not. Refuse to show the license or surrender the concealed weapon to any peace officer upon . demand. • Impede any peace officer in the performance of his/her duties. M Present himself/herself as a peace officer to any' person unless he/she is, in fact, a peace officer as defined by California law. • Unjustifiably display a concealed weapon. • Carry a concealed weapon not listed on the permit • Carry a concealed weapon at times or circumstances other than those specified in the permit. ' Pursuant to U.S. Government Code Title 49, Chapter 26, Section 1472 (1) and Federal Aviation Regulation 121 .583, a license to carry a concealed weapon does not authorize a person to carry a firearm, tear gas, or any dangerous weapon aboard commercial airlines. Further, a person must declare that he/she is carrying such firearm, tear gas, or dangerous weapon BEFORE entering the boarding area of an air terminal where the security checks are made. Such violation can result in arrest by law enforcement. - Any violation of,tle restrictions or conditions may invalidate the CCW license and may void any further use of the license'until reinsta&1 by the licensing authority. Any arrest for a felony or serious misdemeanor, including driving under the influence of alcohol and/or drugs, is cause for invalidating the license. 11.1 State of California, Department of Justice Standard Application for CCW License Section 2 Applicant Clearance Questions - (continued) S. List all traffic violations (moving violations only) and motor vehicle accidents you have had in the last five years. (Use additional pages if necessary.) 00J)Agency I Citation Violation / Accident Date ( c,// 7/0 6 ;_ *1/ ' 9. C$I? (1 id 1P,4e P ci Have you ever been convicted for any criminal offense (civilian or military) in the U.S. or any other country,, NoYes (If yes, explain including date, agency, charges, and disposition.) 10. Have you±hheId any fact that might affect the decision to approve this license? Not"Yes Section If yes, explain): Descriptions1ofIWeaponsI : I List below the weapons you desire to carry if granted a CCW. You may carry concealed only the weapon(s) which you list and describe herein, and only for the purpose indicated. Any misuse will cause an automatic revocation and possible arrest. (Use additional pages if necessary.) Make 1. Model kveSv Caliber 5. 7m 2. 3. -5- Serial No. State of California, Department of Justice Standard Application for CCW License The following Penal Code sections are of special importance to the holder of a COW license regarding the use, carrying, and storage of firearms: Penal Code Section 12051 Applications for CCW Licenses; False Statements (b) Any person who files an application required by subdivision (a) knowing that statements contained therein are false is guilty of a misdemeanor. (c) Any person who knowingly makes a false statement on the application regarding any of the following shall be guilty of a felony: (1) The denial or revocation of a license, or the denial of an amendment to a license, issued pursuant to Section 12050. (2) A criminal conviction. (3) A finding of not guilty by reason of insanity. (4) The Use of a controlled substance. (5) A dishonorable discharge from military service. (6) A commitment to a mental institution. (7) A renunciation of United States citizenship. Penal Code Section 192 - Manslaughter Manslaughter is the unlawful killing of a human being without malice. (a) Voluntary upon a sudden quarrel or heat of passion. (b) Involuntary in the commission of an unlawful act, not amounting to a felony; or in the commission of a lawful act which might produce death, Jn an unlawful manner, or without due caution and circumspection; provided that this subdivision shall not apply to acts committed in the driving of a vehicle. - - Penal Code Section 197 -Justifiable Homicide; Any Person Homicide is justifiable when committed by any person in any- of the following cases: When resisting any attempt to murder any person, or to commit a felony, or to do some great bodily 1. injury upon any person; or, When committed in defense of habitation, property, or person, against one who manifestly intends or 2. endeavors, by violence or surprise, to commit a felony, or against one who manifestly intends and endeavors, in a violent, riotous or tumultuous manner, to enter the habitation of another for the of'dffrthg violence to any person therein; or, When committed in the lawful defense of such person, or of a wife or husband, parent, child, master, 3. mistress, or servant of such person, when there is reasonable ground to apprehend a design to commit a felony or to do some great bodily injury, and imminent danger of such design being accomplished; but such person, or the person in whose behalf the defense was made, if he was the assailant or engaged in mutual combat, must really and in good faith have endeavored to decline any further struggle before the homicide was committed; or, When necessarily committed in attempting, by lawfiil ways and means, to apprehend any person for 4. any felony committed, or in lawfully suppressing any riot, or in lawfully keeping and preserving the peaôe. -7- State of California, Department of Justice Standard Application for CCW License Penal Code Section 198 Justifiable Homicide; Sufficiency of Fear (Limitation of Self-defense of Property Rule) A bare fear of the commission of any of the offenses mentioned in subdivisions 2 and 3 of Section 197, to prevent which homicide may be lawfully committed, is not sufficient to justify it. But the circumstances must be sufficient to excite the fears of a reasonable person, and the party killing must have acted under the influence of such fears alone. - Penal Code Section 199 Justifiable and Excusable Homicide; Discharge of Defendant The homicide appearing to be justifiable or excusable, the person indicted must, upon his trial, be fully acquitted and discharged. - Penal Code Section 12035 Storage of Firearms Accessible to Children (a) As used in this section, the following definitions shall apply: (1) "Locking device" means a device that is designed to prevent the firearm from functioning and when applied to the firearm, renders the firearm inoperable. (2) "Child" means a person under the age of 16 years. (3) "Off-premises" means premises other than the premises where the firearm was stored. (4) "Locked container" has the same meaning as set forth in subdivision (d) of Section 12026.2. (b)(1) Except as provided in subdivision (c), a person commits the crime of "criminal storage of a firearm of the first degree" If he or she keeps any loaded firearm within any premise which is under his or her custody or control and he or she knows or reasonably should know that a child is likely to gain access to the firearm without the permission of the child parent or legal guardian and the child obtains access to the firearm and thereby causes death or great bodily injury to himself, herself, or any other person. (2) Except as provided in subdivision (c), a person commits the crime of "criminal storage of a firearm of the second degree" if he or she keeps any loaded firearm within any premise which is under his or her custody or control and he or she knows or reasonably should know that a child is likely to gain access to the firearm without the permission of the child's parent or legal guardian and the child obtains access to the firearm and thereby causes injury, other than great bodily injury, to himself, herself, or any other person, or carries the firearm either to a public place or in violation of Section 417. (c) Subdivision (b) shall not apply whenever any of the following occurs: (1)The child obtains the firearm as a result of an illegal entry to any premises by any person. (2) The firearm is kept in a locked container or in a location that a reasonable person would believe to be secure. (3)The firearm is carried on the person or within such a close proximity thereto so that the individual can readily retrieve and use the firearm as if carried on the parson. (4) The firearm is locked with a locking device that has rendered the firearm inoperable. (5)The person is a peace officer or a member of the armed forces or national guard and the child obtains the firearm during, or incidental to, the performance of the person's duties. (6) The child obtains, or obtains and discharges, the firearm in a lawful act of self-defense or defense of another person, or persons. (7) The person who keeps a loaded firearm on any premise which is under his or her custody or control has no reasonable expectation, based on objective facts and circumstances, that a child is likely to be present on the premise. - -8- State of California, Department of Justice Standard Application for CCW License Section 5 - Applicable California Penal Code Sections - (continued) Penal Code Section 12036 -Firearms Accessed by Children and Carried Off-premises (a) As used in this section, the following definitions shall apply: (1) 'Locking device" means a device that is designed to prevent the firearm from functioning and when applied to the firearm, renders the firearm inoperable. (2)"Child" means a person under the age of 16 years. (3) "Off-premises" means premises other than .the premises where the firearm was stored. (4) "Locked container" has the same meaning as set forth in subdivision (d) of Section 12026.2. (b) A person who keeps a pistol, revolver, or other firearm capable of being concealed upon the person, loaded or unloaded, within any premise that is under his or her custody or control and he or she knows or reasonably should know that a child is likely to gain access to that firearm without the permission of the child's parent or legal guardian and the child obtains access to that firearm and thereafter caries that firearm off-premises, shall be punished by imprisonment in a county jail not exceeding one year, by a fine not exceeding one thousand dollars ($ 1,000), or by both that imprisonment and fine. (c) A pistol, revolver, or other firearm capable of being concealed upon the person that a child gains access to and carries off-premises in violation of this Section shall be deemed "used in the commission of any misdemeanor as provided in this code or any felony" for the purpose of subdivision (b) of Section 12028 regarding the atthority to confiscate firearms and other deadly weapons as a nuisance. (d) This Section shall not apply if any one of the following circumstances exists: (1) The child obtains the pistol, revolver, or other firearm capable of being concealed upon the person as a result of an illegal entry into any premises by any person. (2) The pistol, revolver, or other firearm capable of being concealed upon the person is kept in a locked container or in a location that a reasonable person would believe to be secure. (3) The pistol, revolver, or other firearm capable of being concealed upon the person is locked with a locking device that has rendered the firearm inoperable. (4) The pistol, revolver, or other firearm capable of being concealed upon the person is carried on the person within such a close range that the individual can readily retrieve and use the firearm as if carried on the person. (5) The person is a peace officer or a member of the armed forces or national guard and the child obtains the pistol, revolver, or other firearm capable of being concealed upon the person during, or incidental to, the performance of the person's duties. The child obtains, or obtains and discharges, the pistol, revolver, or other firearm capable of being (6) concealed upon the person in a lawful act of self-defense or defense of another person or persons. (7) The person who keeps a pistol, revolver, or other firearm capable of being concealed upon the person has no reasonable expectation, based on objective facts and circumstances, that a child is likely to be present on the premises. -9- State of California, Department of Justice Standard Application for CCW License I accept and assume all responsibility and liability for, injury to, or death of any person, or damage to any property which may result through any act or omission of either the licensee or the agency that issued the license. In' the event any claim, suit or action is brought against the agency that issued the license, its chief officer or any of its employees, by reason of, or in connection with any such act or omission, the licensee shall defend, indemnify, and hold harmless the agency that issued the license, its chief officer or any of its employees from such claim, suit, or action. I understand that the acceptance of my application by the licensing authority does not guarantee the issuance of a license and that fees and costs are not refundable if denied. I further understand that if my application is approved and I am issued a license to carry a concealed weapon, that the license is subject to restrictions placed upon it and that misuse of the license will cause an automatic revocation and possible arrest and that the license 'may also be suspended or revoked at the discretion of the licensing authority at any time. I am aware that any use of a firearm may bring criminal action or civil liability against me; I have read, understand, and agree to the CCW license liability clauses, conditions, and restrictions stated in this Application and Agreement to Restrictions and to Hold Harmless. I have read and understand the applicable Penal Code sections regarding False Statements on a CCW Application, Manslaughter, Killing in Defense of Self or Property, Limitation on Self-defense and Defense of Property, and Child Access and Firearm Storage, stated in this application. I have read and understand Attachment I California Prohibiting Categories for a CCW License, Attachment 2 California Prohibitihg Misdemeanors, and Attachment 3 Federal Prohibiting Categories for Possessing - - - Firearms. I further acknowledge that these Prohibiting Categories can be amended or expanded by state or federal legislative or regulatory bodies and that any such amendment or expansion may affect my eligibility to hold a CCW. -311-~Lllo Applicant bTnature Date ' Date Witness Signature I Badge Number -10- State of California, Department of Justice Standard Application for CCW License Have you ever been in a mental institution, treated for mental illness, or been found (If yes, explain): not-guilty by reason of insanity? No Yes 2. _______ Are you now, or have you ever been, addicted to a controlled substance or alcohol, or have you 3. ever utilized an illegal controlled substance, or have you ever reported-to a (If yes, explain): Yes detoxification or drug treatment program? No (/t 4. 5. Have you ever been involved in an incident involving firearms? Not-"'es (If yes, explain): Have you)een involved in a domestic violence incident? (If yes, explain): L-*-' Yes No 6. List any arrests or formal charges, with or without disposition, for any criminal offenses within the U.S. or any other country (civilian or military). ., -''o..s /' 00 , CA v;,i0 1 o4Oc rtsd r I Sie-Vt 4' 4- State of California, Department of Justice Standard Application for CCW License Applicant Name: /Vô Middle First Last Age: Date of Birth: 3 -7 Social Security No.: California DLAD No.: Driver's License Restrictions: Number Street Apt. City State Zip Apt City •State Zip Mailing Address (if different).: Number Street Business Phone Number: (' Business Address: Number 1. Apt Street List all previous home addresses for the past five years, -11- City State Zip State of California, Department of Justice Standard Application for CCW License If the CCW license is desired for self-protection, the protection of others, or for the protection of large sums of money or valuable property, you are required to explain and provide good cause for issuance of the license. For example, has your fife or property been threatened or jeopardized? Explain incidents and include dates, times, locations, and names of police agencies to which these incidents were reported. Details of Reason for Applicant Desiring a CCW License (use additional sheets if needed). lip td re Ti jç uiii'III'III,1 r IIC/h 56-r vice- ç - •t! as r I -13- i .3 y? L. .