LI. (.. State of California, Department of Justice Standard Application for CCW License Attachment 2 CALIFORNIA PROHIBITING MISDEMEANORS As of January, 1999 Pursuant to Penal Code (PC) section 12021(c)(1), any person who has been convicted of a misdemeanor violation for any of the following offenses is prohibited from owning, possessing, or having under his or her custody or control any firearms within 10 years of the conviction • Threatening public officers, employees and school officials (PC section 7.1). • Threatening certain public officials, appointees, judges, staff or their families with the intent and apparent ability to catty out the threat (PC section 76). * Possessing a deadly weapon with the intent to intimidate awitness (PC section 136.5), Threatening witnesses, victims, or informants (PC section 140). Attempting to remove or take a firearm from the person or immediate presence of a public or peace officer (PC section 148(d)). • Unauthorized possession of a weapon in a courtroom, courthouse or court building, or at a public meeting (PC section 171(b)), • • , Bringing into or possessing a loaded firearm within the state capitol, legislative offices, etc. (PC section 171c). Taking into or possessing loaded firearms within the Governor's Mansion or residence of other constitutional officers, etc. (PC section 17 1(d)), • Supplying, selling or giving possession of a firearm to a personfor participation in criminal street gangs (PC section 186.28). • Assault (PC sections 240, 241) • Battery (PC sections 242, 243), • Assault with a stun gun or Taber weapon (PC section 244.5) • Assault with deadly weapon or force likely to produce great bodily injury (PC section 245). • Assault with a deadly weapon or instrument, by any means likely to produce great bodily injury or with a stun gun or Taber on a school employee engaged in-performance of duties (PC section 245.5), • Shooting at an inhabited or occupied dwelling house, building, vehicle, aircraft, horsecart or camper (PC section 246). • Discharging a firearm in a grossly negligent manner (PC section 246.3) • Shooting at an unoccupied aircraft, motor vehicle, or uninhabited building or dwelling house (PC section 247) • Inflicting corporal injury on aspouse or significant other (PC section 273,5) • Willfully violating a domestic protective order (PC section 273,6). 17— / ( State of California, Department of Justice Standard Application for CCW License Attachment 2 (Continued) CALIFORNIA PROHIBITING MISDEMEANORS As of January, 1999 • • Drawing, exhibiting, or using any deadly- weapon other than a firearm (PC sections 417(a)(1), 417(a)2)). Brandishing a fireañn in presence of a peace officer (PC section 417.1 repealed by stats. 1998). - Drawing or exhibiting, selling, manufabturing, or distributing firearm replicas or imitations (PC section 417.2). • Inflicting serious bodily injury as a result of brandishing (PC section 417.6). Bringing into or possessing firearms upon or within public schools and grounds (PC section 626.9). • Stalking (PC section 646.9). • Armed criminal action (PC section 12023), Possessing a: deadly weapon with intent to, commit an assault (PC section 12024). Driver or any vehicle who knowingly permfs another person to discharge a firearm from the vehicle or any • • person who will fully and maliciously discharges a firearm from a motor vehicle (PC sections 12034(b), • 12034(d)). Criminal possession of a firearm (PC section 12040). Firearms dealer who sells or transfers or gives possession of any firearm to a minor or a handgun to a person under the age of 21 (PC section 12072(b)). • • • • Various violations involving sales and transfers of firearms (PC section 12072(g)(3)). Person or corporation who sells any concealable firearm to any minor (PC section 12100(a) —repealed by. stats, 1994). Unauthorized possession/transportation of a machine gun (PC section 12220). Possession of ammunition designed to penetrate metal or armor (PC' section 12320). Carrying a ooncealed br loaded firearm or other deadly weapon or wearing a peace officer uniform, while picketing (PC section 12590). • Bringing firearm related contraband into juvenile hail (WIC section' 871.5). • Bringing firearm related contraband into a. youth authority institution (WIC section 1001,5), 'Purchase, possession, or receipt of a firearm oi 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 (WIC section 8100). Providing a. firearm or deadly weapon to a person described in WIC sections 8100 or 8103 (WIC section 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 a conservatorship (WIC section 8103). V ( State of California, Department of Justice Standard Application for CCW License Attachment 3 FEDERAL PROHIBITING CATEGORIES FOR POSSESSIN G FIREARMS Gun Control Act of 1968, Title 18 U.S.C. Chapter 44 As of January, 1999 Pursuant to Section p22, any person listed below is prohibited from possessing, shipping, transporting, or receiving any firearm, who: Has been convicted in any court of a crime punishable by imprisonment for a term exceeding one year. Is a fugitive ilom justice. Is an unlawful user of or addicted to any controlled substance. Has been adjudicated as a mental defective or committed to a mental institution. Is an alien illegally or unlawfully in the United States. Has been discharged from the Armed Forces under dishonorable conditions. Having been a citizen of the United States, has renounced US. citizenship. Is subject to a court order that restrains the orson from harassing, stalking, or threatening an intimate partner or child of such intimate partner. Has been convicted in any court of a misdemeanor crime of domestic violence. • Is under indictment for a crime punishable by imprisonment for a term exceeding.one year. • Has an out-of-state prohibitive criminal history. Has a prior denial on a previous National Instant Criminal Background Check System (NICS) inquiry. -19- California Depart ment of Josjce -. Hann Safety Certificate • Last Name CA First Name dver's Uce or 5 MJ. pate or Iss ate -_Expira - _ Signature • fir U;jq 13 E CLSS STATE OF CALIFORNIA BOF 4012 (Rev. 11/2012) DEPARTMENT OF JUSTICE PAGE 1°f 15 CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS. STANDARD IN AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON . Arit California Penal Code sections 2650 and 26155 provIe that a sheriff of a county 4r 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 theperson (CCW license). Penal Code section 26175 requires the Attorney GQrieral to prescribe a statewide standard application form for a CCW license. Who May be Issued a License The licensing authority specified in Penal Code sections 26150 and 26155 (a sheriff or the chieforother 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 othe CCW license. All applicants for a CCW license will be fingerprinted and state and federal records will be checked to determine if they are eligible to possess firearms. The attachment to this application list all categories that would prohibit a person 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: 1. A license to carry concealed a pistol, revolver, or other firearm capable of being concealed upon the person. 2. 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.the county a pistol, revolver, or other firearm capable of being c9ncealed upon the person. / Traini ng Required Pend Code sections 26150 and 26155 specify 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 theterm for which the CCW license is granted. For license renewal applicants, the course of training may beany course acceptable to the licensing authority, shall be no less than four hours in length, and shall include instruction on firearm safety and the law regarding permissible use of a firearm. Eychological Testing In addition to licensing requirements as specified by the licensing authority, jurisdictionC 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. (Pen. Code, § 26190, subd. 43i. STATE OF CALIFORNIA B0F4012 (Rev. 11/2012) - CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS DEPARTMENT OF JUSTICE PAGE 2OfI3 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON Completing the Application Answering all the questiohs on this standard application does not guarantee the issuance of a CCW license. The determination whether to issue the license is at the discretion of the licensing authority. Pursuant to Penal Code section 26160, each licensing authority, in addition to using the state standard application form, will have a written policy summarizing what they require. Prior to issuing a COW license, 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 COW license shall be issued. The applicant shall not be required to complete any additional application or form for a CCW license, or to provide any information other than that necessary to complete this standard application form except to clarify or Interpret information provided herein. (Pen. Code, § 26175, subd. (g).) The applicant will certify under penalty of perjury that all answers provided are true and correct to the best of their knowledge and belief. The applicant will also acknowledge that information disclosed on this application may be subject to public disclosure. Important Instructions 1. Complete, read, and sign Sections'l through 5, as directed. Use additional pages if more space is required. 2. Sections 6, 7, and 8 must be completed in the presence of an official of the licensing agency. 3. 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. STATE OF CALIFORNIA BOF 4012 (Rev. 11/2012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS DEPARTMENT OF JUSTICE PAGE 4 of 13 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON 5. Are you now, or have you been, a party to a lawsuit in the last five years? If yes, please explain. flYES 3. Are you now,&r-have you been, subject to a restraining order(s) from any court? If yes, please explain. DYES NNO 7. Are yoU on probation or parole from any state for conviction of any offense including traffic? If yes, please flYES explain. NO. 8. List all traffic violations (moving violations only) and motor vehicle accidents you have had in the lastfive years. Use additional pages if necessary. Violation/Accident Agency Citation No. Date" Violation/Accident Agency Citation No. Date Violation4,ccident Agency Citation No. Date Violation/Accident Agency Citation No. Date Violation/Accident Agency Citation No, Date 14 - 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 We, agency, charges and disposition. flYES 1NO 10. Have you withheld any fact that might affect the decision to approve this license? If yes, please explain. EYES STATE OF CALIFORNIA BOF4O2 (Rev. 1112012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON DEPARTMENT OF JUSTICE PAGE 3 of 13 Official Use Only Type of License Requested ri Judge Standard fl Reserve Officer f] 90 Day [] Initial Application Renewal Application that and truthful in providing information on this application. I understand that I am obligated to be comp of the informati 1r'" rthieP b1khrirnay be subject to public disclosure. " Date 6 fkJ -0 U Witness Signature Date Badge Number Lki Last Name JfA If Applicable, Maiden Name or Other Names(s) Used 5k(j F/A7,/2/HTo City of Residence DatefBirthON Height CAW County of Residence • r%/c-/ii A Country of Citizenship' Place of Birth (City, County, State) ' ) EY , Color Weigh 4® rm 1WF 1. Do you now have, or have you ever had, a license to carry a concealed weapon (CCW)? If yes, please MYES flNO enter the issuing agency name, issue date and CCW license number. Use additional pages if necessary. oc-e tJT C1 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, flYES NNO and the reason for denial. Agency Name • Date Reason for Denial 3. Have you ever held and subsequently renounced your United States citizenship? If yes, please explain. DYES NO 4. If you served with the Armed Forces, were you ever convicted of any charges or was your discharge other DYES EINO than honorable? If yes, please explain. STATE OF CALIFORNIA BOF 4012 (Rev. 11/2012) DEPARTMENT OF JUSTICE PAGES 0113 CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON List below the weapons 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 revocation and possible arrest. Use additional pages if necessary. WA-1L. Make Model Caliber ___________ Make 4 J Make LA/fl - Model Model IS16 Caliber P g Seramber Caliber The licensee is responsible for all liability for, injury to, or death of any person, or damage to any property whidh 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 off iceror 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 isued 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 g ranted 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 purpos.e of dispensing alcoholic beverages for on-site consumption.. • 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. •. 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. Title 49, section 46505 of the United States Code states that 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 declre 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 50F4012 (R 11/2012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS DEPARTMENTOFJUST]OF PAGE 6 of 13 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON The following Penal Code sections are of special importance to the holderof a CCW license regarding the use, carrying, and storage of firearms Penal Code section 26180 False Statement on Application Form (a) Any person who files an application required by Section 26175 knowing that statements contained therein are false is guilty of a misdemeanor. (b) Any person who knowingly makes a false statement on the application regarding any of the following is guilty of a felony (1) The denial or revocation of a license, or the denial of an amendment to a license, issued ursuant to this article. (2) A criminal conviction. (3) A finding of not guilty by reason of insanity. (4) The use of a controlled substance. () 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. This subdivision shall not apply to acts committed in the driving of a vehicle. - Penal Code section 197 Justifiable Homicide; Any Person Homicide is also justifiable when committed by any pers9n 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 injury upon any 1. person; or, When committed in defense of habitation, property, or person, against one who manifestly intends or endeavors, by 2. violence or surprise, to commit a felony, or against one who manifestly intends and endeavors, in a violent, riotousor 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, p'arent, child, master, mistress or 3.1 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 lawful ways and means, to apprehend any person for any felony 4. committed, or in lawfully suppressing any riot, or in lawfully keeping and preserving the peace. Penal Code section 198 - Justifiable Homicide; Sufficiency of Fear A bare fear of the commission of any of the offenses mentioned in subdivisions 2 and 3 of Seótion 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 25100 Criminal Storage of Firearm - (a) Except as provided in Section 25105, a person commits the crime of "criminal storage of a firearm of the first degree" if all of the following conditions are satisfied. (1) The person keeps any loaded firearm within any premises that are under the person's custody or control. (2) The person 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. (3) The child obtains access to. the firearm and thereby causes death or great bodily injury to the child or any other person. STATE OF CALIFORNIA HOP 4012 (Rev. 11/2012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS DEPARTMENT OF JUSTICE PAGE 7 of 13 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON (b) Except as provided in Section 25105, a person commits the crime of "criminal storage of a firearm of the second degree" if all of the following conditions are satisfied: (1) The person keeps any loaded firearm within any premises that are under the person's custody or control. (2) The person 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. (3) The child obtains access to the firearm and thereby causes injury, other than great bodily injury, to the child or any other person, or carries the firearm either to a public place or in violation of Section 417. Penal Code section 25105 Exceptions Section. 25100 does not apply whenever any of the following occurs: (a) The child obtains the firearm as a result of an illegal entry to any premises by any person. (b) The firearm is kept in a locked container or in a location that a reasonable person would believe to be secure. (c) The firearm is carried on the person or within close enough proximity thereto that the individual can readily retrieve and use the firearm as if carried on the person. (d) The firearm is locked with a locking device, as defined in Section 16860, which has rendered the firearm inoperable. (e) The person is a peace officer or a member of the Armed Forces or the National Guard and the child obtains the firearm during, or incidental to, the performance of the person's duties. (f) The child obtains, or obtains and discharges, the firearm- in a lawful act of self-defense for defense of another person. (g) The person who keeps a loaded firearm on any premise that is under the person's custody or control has no reasonable expectation, based on objective facts and circumstances, that a child is likely to be present on the premise. - Penal Code section 25200 Storage of Firearm where Child Obtains Access and Carries Firearm Off-Premises (a) If all of the following conditions are satisfied, a person shall be punished by imprisonment in a county jail not exceeding one year, by a fine not exceeding onethousand dollars ($1,000), or by both that imprisonment and fine: (1) The person keeps a pistol, revolver, or other firearm capable of being concealed upon the person, loaded or unloaded, within any premises that are under the person's custody or control. (2) The person 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. (3) The child obtains access to that firearm and thereafter carries that firearm off-premises. (b) If all of the following conditions are satisfied, a person shall be punished byimprisonrnent in a county jail not exceeding one year, by a fine not exceeding five thousand dollars ($5,000), or by both that imprisonment and fine: (1) The person keeps any firearm within any premises that are under the person's custody or control. (2) The person knows orreasonably should know that a child is likely gain access to the firearm without the permission of the child's parent or legal guardian. (3) The child obtains access to thp firearm and thereafter carries that firearm off-premises to any public or private preschool, elementary school, middle school, high school, or to any school-sponsored event, activity, or performance, whether occurring on school grounds or elsewhere. (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 deempd "used in the commission of any misdemeanor as provided in this code or any felony" for the purpose of Section 29300 regarding the authority to confiscate firearms and other deadly weapons as a nuisance. (d) As used in this section, "off-premises" means premises other than the. premises where the firearm was stored. - Penal Code section 25205 Exceptions Section 25200 does not apply if any of the following are true: (a) The child obtains the firearm as a result of an illegal entry into any premises by any person. (b) The firearm is kept in a locked container or in a location that a reasonable person would 1elieve to be secure. (c) The firearm is locked with a locking device, as defined in Section 16860, which has rendered the firearm inoperable. (d) the firearm is carried on the person within close enough range that the individual can readily retrieve and use the firearm as if carried on the person. (e) 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. The child obtains, or obtains and discharges, the firearm in a lawful act of self-defense or defense of another person. (f) (g) The person who keeps a firearm has no reasonable expectation, based on objective facts and circumstances, that a child is likely to be present on the premises. - STATE OF OAUFORNIA CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS 00F4012 (ReV. 11/2012) DEPARTMENTOFJUSTICE PAGE 80112 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON 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 an 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 any application by the licensing authority dos 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 carrya concealed weapon, that the license is subject tor restrictions placed upon it and that misuse of the license will cause an automatic revocation and possible arrest and that the license.rnay also be suspended or revoked at the discretion of the licensing authority at anytime. 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 the Firearms Prohibiting Categories attachment to this application. I further acknowledge that these prohibiting categories can be amencId 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. Date V'Atness Signature Badge Number. Date I STATE OFCALIFORNIA BOF4012(Rov.11/2012) KIA r W ,r OF DEPARTMENT OF PAGE of 13 JUSTICE BUREAU OF FIREARMS STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON - - #ao of Birth P0_Lf First Name Applicant Last Name Middle Name Age WW- qQt2( 6I1-f\ çuo CA State Zip Code TelephonNu1r (IJay) City - Ridence Auui - - State Zip Code Telephone Number (Evening) Mailing Address (If diffe Spouse/DomesticPaThiër Last Name First Name Physical Address (if different than applicant) 'Wfl9dle Name City State Zip Code Telephone Number Business/Employer Name Applicant Occuption 2il Bssimpioyer Mress uIty - W State Zip Code Telephone Nu 4T j '1. List all previous home addresses for the past five years. Use additional pages if necessary. Address State Zip Code Address City State Zip Code res City State Zip Code Address City State Zip Code 2. Have you ever been in a mental institution, treated for mental Illness, or been found not-guilty by reason of insanity? If yes, please explain. 3. Are you now, or have you ever been, addicted to a controlled substance or alcohol, pr have you ever utilized an illegal controlled substance, or have you ever reported to a detoxification or drug treatment program. If yes, please explain. EYES IlNo STATE OF CALIFORNIA OF 4012 (Rev. 11/2012) ALIFORNIA C DEPARTMENTOFJUSTICE PAGE IQoIIS it JUSTICE BUREAU OF FIREARMS STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY.A CONCEALED WEAPON 90 MM 4. Have you ever been involved in an incident involving tirearms? IT yes, please explain. DYES 5. Have you ever been involved in a domestic violence incident? If yes, please explain. DYES JNO 4 6. List any arrest or formal charges, with or without disposition, for any criminal offenses within the U.S. or any other country (civilian or military) []YES )No If the COW 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 Issu ance of the license. For example, has your life or property been threatened or jeopardized? Expla in incidents and include dates, times, locations, and names of police agencies to which these incidents were reported. Details ot Reason tor Applicant iesiring a uuvv jicense. use suumurisi peye It I ii iy. STATE OF CALIFORNIA DEPARTMENT OF JUSTICE PAGE 12 of 18 ATTACHMENT SOP 4012 (Rev. 11/2012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS .D FIREARMS PROHIBITING CATEGORIES State and federaliaw make it unlawful for certain persons to own and/or possess firearms, including: • Any person who is convicted of a felony, or any offense enumerated In Penal Code sections 29900 or 29905 • Any parson who is ordered to not possess firearms as a condition of probation or other court order listed in Penal Code section 29815, subdivisions (a) and (b) • Any parson who Is convicted of a misdemeanor listed In Penal Code section 29805 (refer to List of Prohibiting Misdemeanors) • Any person who is adjudged a ward of the juvenile court because he or she committed an offense listed in Welfare and Institutions Code section 707(b), an offense described In Penal Code section 1203.073(b), or any offense enumerated in Penal Code 6ection 29805 • Anypern who is subject to a temporary straining order or an injunction issued pursuant to Cpde of Civil Procedure sections 627.6 or 527.8, a protactive order as defined in Family Code section 6218, a protective order issued pursuant to Penal Code sections 136.2 o.r 646.91, or a pfotective ordr issued pursuant to Welfare and Institutions Code section 15657.03 • Any person who is found by a court to be a danger to himself, herself, or others because of a mental illness Any person Who is found by a court to be mentally incompetent to stand trial • Any person who is found by a court to be not guilty by reason of insanity • Any person who Is adjudicated to be a mentally disorde.red sex offender • Any person who is placed on a conservatorship because he or she is gravely disabled as a result of a mental disorder, or an impairment by chronic alcoholism • Any person who communicates a threat to a licnsed psychotherapist against a reasonably identifiable victim, that has been reported by the psychotherapist to law enforcement • Any person who Is taken into custody as a danger to self or others under Welfare and Institutions Code section 5150, assessed under Welfare and Institutions Code section 5151, and admitted to a mental health facility under Welfare and Institutions Coda sections 5151, 5152, or certified under Welfare end Institutions Cods sections 6260, 5260, and 5270.15 • Any person who is addicted to the use of narcotics (state and federal) • Any parson who is under indictment or information in any court for a crime punishable by imprisonment for a term exceeding one year (federal) • Any parson who has been discharg ed from the military under dishonorable conditions (federal) • Any person who Is an Illegal alien (federal) • Any person who has renounced his or her US Citizenship (federal) • Any person who is a fugitive from justice (federal) STATE OF CALIFORNIA E0F4012 (Rev. 11/2012) CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS DEPARTMENTOFJUSTICE PAGE 11 of 13 STANDARD INITIAL AND RENEWAL APPLICATION FOR LICENSE TO CARRY A CONCEALED WEAPON 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 Iistd 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 620 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 declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date Signature badge Number Date J. -