I State of Calili,roia, epartment of Justice Standard Application for CCW License Official Use Only Typo of Permit Requested O Standard () Judge o Reserve Officer () 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 subje ct to public disclosure. Applicant Signat Date LT. TERESA GRACIE 6 Witness Signature I Badge Number /~ Date Lam, George Name: ___________ Last First Middle If Applicable Maiden Name or City and of kesid ournry of Citizenship:... Date of I3irth, ________________ China Place of Birth: .. ty Heig-.Weig L Color Eyes. County State Color Bair Do you. now have, or have you ever had a license to carry a concealed weapon (CCW)? NoV Yes (If yes, please indicate below. Use additional pages if necessary) Issuing Agency 2. . . ' Issue Date ccw#___________ have you ever applied for and been denied a license to carry a concealed weapon? Yes_____ (If yes, give agency name, date and reason for denial.) No__V__ ( State of California, Department of Justice Standard Application for CCW License 3. Have vjiu ever held and subsequently renounced your United States citizenship? (If yes, explain): No V Yes 4. If you served with the Armed Forces, were you ever convicted of any charges or was your discharge other than honorable? No 5. Are yo u ow, or have you been a party to a lawsuit in the last five years? No 6. Yes_____ (If yes, explain): V (If yes, explain): Yes Are yu now, or have you been, under a restraining order(s) from any court? No _Yes_____ (If yes, explain),: 7. Are you on pro.ation or parole from any state for conviction of any offense including traffic? No V Yes (If yes, explain): ( State of California, Department of Justice Standard Application for CCW License 8. List all traffic violations (moving violations only) and motor vehicle accidents you have had in the last five years. (Use additional pages if necessary.) 9. Have you ever been convicted for any criminal offense (civilian or military) in the U.S. or any,ther country? No _Yes 10. (If yes, explain including date, agency, charges, and disposition.) Have yyn witheld any fact that might affect the decision to approve this license? No __Yes (If yes, explain): 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 Model Caliber 1. 2. 3, -5- Serial No. State of California, 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 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 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: • Consume any alcoholic beverage. • Be in a place having a primary purpose of dispensing alcoholic beverages for on-site consumption. • Be under the influence of any medication or drug, whether prescribed or hot, • 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. • 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 121.5 83, 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 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 paug riiivalidating the license. I eM 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 CCW 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, in 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; 1. When resisting any attempt to murder any person, or to commit a felony, or to do some great bodily injury upon any person; or, 2. When committed in defense of habitation, property, or person, against one who manifestly intends or 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 purpose of offering 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, 4. When necessarily committed in attempting, by lawful ways and means, to apprehend any person for any felony committed, or in lawfully suppressing any riot, or in lawfully keeping and preserving the peace. 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 for the 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's 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 person. 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. - MI ( state of California, Department of Justice Standard Application for CCW License 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. "Child" means a person under the age of 16 years, (2) "Off-premises" means premises other than the premises where the firearm was stored. (3) "Locked container" has the same meaning as set forth in subdivision (d) of Section 12026.2 (4) (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 carries 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 "usd 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 authority to confiscate firearms and other deadly weapons as a nuisance. (d) This Section shall not apply if 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, The pistol, revolver, or other firearm capable of being concealed upon the person is kept in a locked (2) 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. (6) The child obtains, or obtains and discharges, the pistol, revolver, or other firearm capable of being 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. in ( ( 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 1 California Prohibiting Categories for a CCW License, Federal Prohibiting California Prohibiting Misdemeanors, and Attachment 3 Attachment 2 Categories for Possessing Firearms. I further acknowledgd 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. - - - 4: App1icaWiguatui'e 7/ Date LT. TERESA GRACIE #733 Witness Signature / Badge Number -10- State of California, Department of Justice Standard Application for CCW License Applicant Name: (f- Date of Birth: MjW First Last Age . Social Security No.: California DL/H) No.: Driver's License Restrictions: -L 0 ....'.-. Mailing address (if different): City Home / Personal Phone Numbers: Spouse's Name and Address: Applicant Occupation: Business / Employer Name: Business Phone Number:. 1. List all previous home addresses for the past five years. Q--- - -11- State qL(\ Zip State of California, Department of Justice Standard Application for CCW License 2. Have you ever been in a mental institution, treated for mental illness, or been found not-guilty by reason of insanity? No _Yes_____ If yes, explain): 3. Are you now, or have you ever been, aIdcited to a controlled substance or alcohol, or have you ever utilied an ilIgal controlled substance, or have you ever reported to a detoxification or drug treatment program? No )( Yes (If yes, explain): 4. Have you ever been involved in an incident involving firearms? No ( Yes_____ (If yes, explain): 5. Have you been involved in a domestic violence incident? No ,( Yes_____ (If yes, explain): 6. List any arrests or formal charges, with or without disposition, for any criminal offenses with the U.S. or any other country (civilian or military). -12- 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 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 sheets if needed). sc e. 5 '__s.___ S tJC & -13- .. State of California, Department of Justice Standard Application for CCW License I hereby 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. Notwithstanding any other provision of law and pursuant to the Public Records Act (Government Code section 6250 et seq.), 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 hereby certify under penalties of perjury and Penal Code section 12051(b) and (c), that the answers I have given are true and correct to the best of my knowledge and belief, and that I understand and agree to the provisions, conditions, and restictibns herein or otherwise imposed. . Applicanaé/ . Date . LT. TERESA GRACIE D( 1S/ Witness Signature / Badge Number ri -14- DEPARTMENT OF JUSTICE .PAGE 13 of 13 ATTACHMENT STATE OF CALIFORNIA 50F4012(Rev.11/2012) ... CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS IREARMS PROHIBITING CATEGORIES F Firearm prohibitions for misdemeanor violations of the offenses listed below are generally for ten years from the date of conviction, but the duration of each prohibition may vary. All statutory references are to the California Penal Code, unless otherwise indicated. Threatening public officers, employees, and school officials (Pen. Code, § 71.) Threatening certain public officers, appointees, judges, staff or their families with the intent and apparent ability to carry out the threat (Pen. Code, § 76.) • Intimidating witnesses or victims (Pen; Code, § 136.1.) • Possessing a deadly weapon with the intent to Intimidate a witness (Pen. Code, § 136.5.) • Threatening witnesses, victims, or informants (Pen. Code, § 140.) • Attempting to remove or take a firearm from the person or immediate presence of a public or peace officer (Pen. Code, § 148(d).) • Unauthorized possession of a weapon In a courtroom. Courthouse, or court building, or at a public meeting (Pen. Code, § 171(b).) • Bringing into or possessing a loaded firearm within the state capitol, legislative offices, etc. (Pen. Code, § 171(c).) • Taking Into or possessing loaded firearms within the Governor's Mansion or residence of other constitutional officers (Pen. Code, 171(d).) • Supplying, selling or giving possession of a firearm to a person for participation In criminal street gangs (Pen. Code, § 186.28.) • Assault (Pen. Code, §§ 240, 241.) • Battery (Pen. Code, §§ 242, 243.) • Sexual Battery (Pen. Code, § 243.4) • Assault with a stun gun or taser weapon (Pen. Code, § 244.5.) • Assault with a deadly weapon other than a firearm, or with force likely to produce great bodily injury (Pen. Code, § 245.) • Assault with-a deadly weapoh or instrument; by any means likely to produce great bodily injury or with a stun gun or taser on a school employee engaged in performance of duties (Pen. Code, § 245.5.) • Discharging a firearm in a grossly negligent manner (Pen. Code, § 246.3.) • Shooting at an unoccupied aircraft, motor vehicle, or uninhabited building or dwelling house (Pen. Code, § 247.) • Inflicting corporal injury ona spouse or significant other (Pen. Code, § 273.5,)* • Wilfully violating a domestic protective order (Pen. Code, § 273.6.) • Drawing, exhibiting, or using deadly weapon other than afirearm (Pen. Code, §417, subd. (a)(1) & (a)(2).) rjur as a result of brandishing (Pen. Code, § 417.6.) • Inflicting serious b • Making threats to dmmit a crime which will result in death or great bodily injury to another person (Pen. Code, § 422.) • Bringing into or possessing firearms upon or within public schools and grounds (Pen. Code, § 626.9.) • Stalking (Pen. Code, § 646.9.) • Armed criminal action (Pen. Code, § 25800.) • Possessing a deadly weapon with intent to commit an assault (Pen. Code, § 17500.) • Driver of any vehicle who knowingly permits another person to discharge a firearm from the vehicle or any person who willfully and maliciously discharges a firearm from a motor vehicle (Pen. Code, § 26100, subd. (b) or (d).) • Criminal possession of a firearm (Pen. Code, § 25300.) • Firearms dealer who sells, transfers or gives possession of any firearm to a minor or a handgun to a person under 21 (Pen. Code, § 27510.) • Various violations involving sales and transfers of firearms (Pen, Code, § 27590, subd. (c).) • Person or corporation who sells any concealable firearm to any minor (former Pen. Code, § 12100, subd. (a).) • Unauthorized possession/transportation of a machine gun (Pen. Code, § 32625) • Possession of ammunition designed to penetrate metal or armor (Pen. Code, § 30315.) • Carrying a concealed or loaded firearm or other deadly weapon or wearing a peace officer uniform while picketing (Pen. Code, § 830.95, subd. (a), - - 17510, subd. (a.) • Bringing firearm related contraband Into juvenile hail (Waif. & Inst. Code, § 871.5.) • Bringing firearm related contraband into a youth authority institution (Wolf. & Inst. Code, § 1001.5.) • Purchase, possession, or receipt of a firearm or deadly weapon by a person receiving in-patient treatment for a mental disorder, or by a person who has communicated to a licensed psychotherapist a serious threat of physical violence against an Identifiable victim (Wolf. & Inst. Code, § 8100.) • Providing a firearm or deadly weapon to a person described in Welfare and Institutions Code sections 8100 or 8103 (WeIf. & Inst. Code, § 8101.) • Purchase, possession, or receipt of a firearm or deadly weapon by a person who has been adjudicated to be a mentally disordered sex offender or found to be mentally incompetent to stand trial, or not guilty by reason of insanity, and individuals placed under conservatorship (Wolf. & Inst. Code, § 8103.) - The following misdemeanor Convictions result in a lifetime prohibition: • Assault with a firearm (Pen. Code, §§ 29800, subd, (a)(1), 23515, subd. (a).) • Shooting at an Inhabited or occupied dwelling house, building, vehicle, aircraft, housecar or camper (Pen. Code, §§ 246, 29800, subd. (a)(1), 17510, 23515, subd. (b).) • Brandishing a firearm in presence of a peace officer (Pen. Code §§ 417, subd. (c), 23515, subd. (d), 29800, subd. (a)(1).) • Two or more convictions of Penal Code sectIon 417, subdivision (a)(2) (Pen. Coda § 29800, subd. (a)().) - * A 'misdemeanor crime of domestic violence" (18 U.S.C. §§ 921 (a)(33)(A), 922(g)(9),) Note: The Department of Justice provides this document for informational purposes only. This list may not be inclusive of all firearms prohibitions. For specific legal advice, please consult with an attorney licensed to practice law in California. -