STATE OF CALIFORNIA DEPARTMENT OF JUSTICE PAGE 3oI1S :.:. . CALIFORNIA D E PARTM E NT OF JUSTICE BUREAU OF FIREARMS BOF4L'12 (Rev.11/2012) STANDARD. INITI AL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON O Official Use Only Type of License Requested Judge Standard 90 Day Reserve Officer . fl E] Renewal Application Initial Application . - . Public Disclosure Admonition: I understand that I am obligated to be complete and truthful in providing information on this application. I understand that all 1teLojimebjectto public disclosure. of the information disclosed by. rne ithis q 71/ Date 0C/// Date Section. 1..AppJicant PersonarJnformatiori . . First Name Last Nä#e J Middle N V fve4f plicablë, Maiden Name or Other Names(s Sorn FvwiCi3c,c) VV1W7?? . City of Residence . tIIt Country of Citizenship County of Residence g jv i_Fn _ Date of Birth Place of Birth (City, County,.State) . -•_______ - Height - Weight _•J . Ha]lr' Eye Color Section 2 Applicant Clearance Queston 1. Do you now have, or have you ever had, a license to carry a concealed weapon .(CCW)? If yes, please enter the issuing agency name, issue date and CCW license number. Use additional pages if necessary. DYES E.NO CCW No. Issue Date Issuing Agency 2. Have - you ever applied for and been denied a CCW license? If yes, please enter the agency name, date, DYES ENO and the reason for denial. Agency Name • Date Reason for Denial 3. Have you ever held and subsequently renounced your yq ai -,citizenship? If yes, please explain. DYES NO ci L td i1WZ 4 If you served with the Armed Forces, were you ever convicted of any charges or was your discharge other DYES E] NO than honorable? If yes, please explain. - STATE OF CALIFORNIA EOF4Oi2(Rev.1112012) DEPARTMENT OF JUSTICE PAGE 4oM3 CALIFORNIA DEPARTMENT OF JUSTICE • BUREAU OF F1I*EARMS STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON " • DYES[2]NO 5. Are you now, or have you been, a party to a lawsuit in the last five years? If yes, please explain. Unless this includes WC. In 2010, Ifiled a WC claim. Are you now, or have you been, subject to a restraining order(s) from acy court'Tlryes, please explain. I have two, criminal protective orders vs two individuals. NYES [JNC ' 7. Are you on probation or parole from any state for conviction of any offense including traffic? If yes, please flYES JNO explain. • 8. List all traffic 'violations (moving violations only) and motor vehicle a ' ccidents you have had in the last five years. Use additional pages if necessary. 111 5/14 accident/no fault Date Citation No. Violation/Accident Agency 3/3/14 Date 5/15/13 Date accident/no fault Violation/Acbidont , ' accident/no fault Vløl,ation/Accident Citation No. Agency ', •. •. Citation No. '' Date Violation/Accident Agency Date Violation/Accident Agency • 9. Have you ever been convicted of any criminal offense (civilian or military) in the U.S. or any other country? If yes, please explain including the date,- agency, charges and disposition. Citation No. Citation No. flYES NO 10. Have you withheld any fact that might affect the decision to approve this license? If yes, please explain. DYES NO STATE OF CALIFORNIA DEPARTMENT OF JUSTICE PAGE 6 o 13 . 00F4012 (Rev. 11/2012) CALIFORNIA DEPAR IIET OF JUSTICE BUREAU OF FIREARMS STANDARD llNflllAL ANb.. RWEWAL APPUCATIION FOR LHCENSE TO CARRY A CONCEALED WEAPON Section 3- Description of Weapons List below the we'apons you desire to carry if granted a CCW license. 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 reveation and possible arrest. Use additional pages if necessary. GLOCK 19 9MM Make Caliber Model Serial Number -. Make Model Caliber Serial Number Make Model Caliber Serial Number Section 4- CCW License Conditions and Restrictions 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 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. The licensee authori±es 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 arisingout 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: • Consume any alcoholic beverage. Be in a place having a primary purpose* of dnsit.alcoholic beMerages for on-site consumption. Be under the influence of any medication or drug, whetheprescriberI or not. o 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. o Present himself/herself as a peace officer to any person unless he/she is, in.fact, a peace officer as defined by California law. o Unjustifiably display a concealed weapon. • Carry a concealed weapon not listed on the permit. o Carry a concealed weapon at times or circumstances other than those specified in the permit. ° o - Title 49, section 46505 of the United States Code states that a license to carry a concealed weapon does not áuthorie a person to carry a firearm, tear gas, or any dangerous weaon aboard commercial airlines. Further, a person must declare that he/she is carrying such firearm, tear gas, or any 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 these restrictions or conditions may invalidate the CCW license and may void any further use of the license until reinstated 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. STATE OF CALIFORNIA BOF 4012 (Rev. 11/2012) DEPARTIVIENTOF JUSTICE CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS STANDARD INITIAL AND RENEWALAPPLIICATHON FOR UCENSE TO CARRY A CONCEALED WEAPON Section 6 Agreement to Restrictions and to Hold HmiIs I accept and assume all responsibility and liability for, injury to, or death of any person, or damage to any property which my result through an act or omission of either the licensee or the agncy 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 s cl-i act or omission, the licensee shall defend, indemnify, and hold harmless the agency that issued the license its chie of its employees from such claim suit or action I understand that the acceptance of any 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 orrevoked at the discretion of the licensing authority at any time. I am aware that an 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 appljcation and Agreement to Restrictions and to Hold Harmless. I have read and understand the applicable Penal Code sections regarding false statements o 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 the Firearms Prohibiting Categories attachment to this application. 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 license. 4 /7-11/ Date ),-//, P Date :T!Ct. STATE OF CALIFORkIA DEPARTMENTOFJUSTICE PAGE 9 of 13 CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS BOF4O2 (Rev. 11/2012) STANDARD INITIAL AND RENEWAL APPLICATI ON FOR LICENSE TO CARRY A CONCEALED WEAPON Section 7 nvest1gator's Inte low Notes Appct Last Name V. First NameJ Date of Birth Age Middle Ne V CA Driver License/I ITNö. Social SeTiry Nb.' NW V , CA Driver License Restrictions MIF V Iesidetiee Address, tate City Mailing Address (if different) State -Zip Code -- City Spouse/Domestic Partner Last Name Zip,çpde Telephqpe I'nmber (Day) TelepTi1iüTh15ëi(Evening) Middle Name First Name NIA Physical Address (if different than applicant) .Ow1c{ V104v40 Applicant Ocupation Q Business/Employer Address State City Zip Code Telephone Number dc 14 lvrcv (Al:)) Business/Employer Name . . State City V Zip Code 1. V List alLprevious borne dsses for the past five years. Use additional pages if necessary. Telephone Number ' ' V V V V Addl City V ress Address . LFflCS( V State M Zip Cod6 City State Zip Code City State Zip Code Ci!. State Zip Code 2. Have you ever been in a mental institution, treated for mental illness, or been found not-guilty by reason of rmin insanity? If yes, please explain. €e mVVr 3. Are you now, or have you ever been, addicted to a controlled substance or alcohol, or have you ever utilized an illegal controlled substance, or have you ever repo rted to a detoxification or drug treatment oroaram. If yes. please explain. V DYES V NO STATE OF CALIFQFW '-f DEPATMENT OF JUSTICE CAUFORNA DEPARTiIIENT OF JUST BUREAU OF FIREARMS • BOF4Q12(Rev.11'2012) PAGE 10 of 13 STANDARD HTML AND RENEWAL APPLIICATOON FOR LOCENSE TO CARRY A CONCEALED WEAPON $ctIon 7 investigators tnteMew. fJOtes Continued 4. Have you ever been involved in an incident involving firearms? If yes, please explairi. DYES 5. Have you ever been involved in a domestic violence incident? lfyes, please explain. No 1 6YES DNO uLU / 'iEZffTi T1 6. List any arrestor formal charges, with or without disposition, for any criminal offenses within the U.S. or any otner country (civilian or paLtJ irfl 0 4 &11kvi cav n,ci bna j4 • n* 1ih( o1 HI )YES ITJNQ 1AV1 (wii p(Mm 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 life 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 pages if necessary Good Cause for Issuance I am a public official in San Francisco. I am certified as a Notary Public. As a notary public I hold many titles that include but are not limited to: Notary Signing Agent, Registered Process Server, and Field Inspector. I am also a certified Fingerprint Technician (FPT) and Live Scan Authorized PpizidtiAP). Most times I carry large amounts of cash and checks in ore at any given time. I am currently completing an HR Block Tax course snHöine Tax Preparer (ITP), which will be another source of income and credentials that I will carry on my person at any given time. I am also a Bishop (Reverend) who holds a Doctor of Divinity Degree (DD). I primarily act as a mobile Independent Contrt IIjywork is primarily in the field. I cover the 9 Bay Area Counties tht include: San Francisco, Alameda, Contra Costa, Solano, Sonoma, Napa, Mann, San Mateo', and Santa Clara.The Field Inspection work gets* dangerous at times. Ihave males who physically stalk, harass, and attack me when I am performing field inspections on commercial properties. I contract with at least a half a dozen agencies for assistance in iecrne 1 r1gpeityoI makincnl1ecfion effo ts ç1bt settlements I am not able to physically or physical status. wu I perform CPR classes as an Instructor and (AP) via the American Heart Association (AHA) and American Red Cross (ARC). I will soon become a training center (TC) in San Francisco County, which will also increase the amount Of revenue I will carry at any given time due to the increased demand of students and medical professionals in California. Quite frankly, you might consider me a walking vault. Due to the loan documents that I carry as well as personal informtion fQr the background checks I perform, Ikeep locked safes and briefcases that the Finally, I do have a history of Francisco County can't handle;I h" ave, èiEiT and Liyf ma sebided areanf San Frarco wit - ddress to ye acriminal o have attem fforts to prevent Tgchild support. BasIcally, our lives have bee] Tnd physically threatened. I have been having problems since 2008. I have contacted the SFPH, SFFD, SV1Jtc with. jo avail. I am basically on my own in this I do live in fear 24/7. The last situation. I have to protect incident of violation of the-77 sin May of this year. Ido my best to avoid any confrOntation or visit any areas known to me that I may have altercation or run- ins with them at all costs. I can't keep hiding to avoid these people. I have a life to lead and a business to run. " " - DEPARTMENT OF JUSTICE PAGE 11 of 13 CALIFORNIA DEPARTM ENT OF JUSTI CE BUREAU OF FIREARMS STATE OF CALIFORNIA B0F4012 (Rev 11/2012) STANDARD ftUTllAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON Section 8 Release. ofLnfôrrnatioi and.. Declâration I herby give permission to the agency to which this application is made to conduct a background investigation of me and to contact any person or agency who may add to or aid in this investigation. I further authorize persons, firms, agencies and institutions listed on this application to release or confirm information about me and statements I have made as contained in this application. toLc Records Act (Government Code section 6250 et seq.), Notwithstanding any other provision of la I understand that information contained in this application may be a matter of public record and shall be made available upon request or court order. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. q j — i/ Date hv) Date : Ak - J..- - •'- A- - - _i