Fillable DEPARTMENT OF SAFETY DIVISION OF STATE POLICE (Town of Newton)

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DEPARTMENT OF SAFETY DIVISION OF STATE POLICE (Town of Newton)

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BROWSE TOWN OF NEWTON (NH) FORMS

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State of New Hampshire
DEPARTMENT OF SAFETY
DIVISION OF STATE POLICE
RESIDENT PISTOL/REVOLVER LICENSE
RENEWAL APPLICANTS PLEASE COMPLETE: NH Pistol/Revolver License #:
Expires
An incomplete application will be returned.
FILE #:
Name
Date of Application
Mailing Address:
Street
Driver’s License No.
City/Town
Social Security No.
State
Zip
Telephone No.
(optional)
Legal Address (If different from above):
(optional)
Date of Birth
Place of Birth
Original
Renewal
Height
Hair
Sex
Weight
Eyes
Race
Occupation:
Present Employer:
Employer’s Address:
If you answer “Yes” to any of the following questions, you must provide complete details with this application.
Have you ever had a license to carry denied in this or any other state?
Yes
No
Have you ever been convicted of a felony, in this or any other state, which has not been annulled?
Yes
No
Are you an unlawful user of or addicted to any controlled substance?
Yes
No
Have you ever been adjudicated as a mental defective by a court or committed by a court to any
mental institution?
Yes
No
Have you ever been convicted in any court of a misdemeanor crime of domestic violence?
Yes
No
For what reason(s) do you make application to carry a pistol in New Hampshire?
Name and Complete Mailing Address of three (3) references:
1.
2.
3.
(NAME)
(NAME)
(NAME)
(ADDRESS)
(ADDRESS)
(ADDRESS)
SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS APPLICATION: Read the following carefully before you sign. A false statement on any part of this application will be just cause for
refusal of any application of any license issued under the provisions of RSA159 and is punishable under RSA 641:3.
•
I understand that any information I give may be investigated as allowed by law.
•
I consent to the release of information about my ability and fitness to carry a pistol/revolver by employers, schools, medical/ psychiatric
services, law enforcement agencies, and other individuals and organizations, to my local police chief, his or her designee, and/or
authorized employees of the State of New Hampshire.
•
I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete and made in good faith.
SIGNATURE OF APPLICANT:
Date:
OFFICIAL USE ONLY:
Approved
Denied
APPROVING OFFICIAL:
DSSP85 (Rev 03/17)
DATE:
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DEPARTMENT OF SAFETY DIVISION OF STATE POLICE (Town of Newton)

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Completed 4 August 2020

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