_____________________________
_____________________________
___
________________________________________________________________________ _______________________________
STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
FIREARMS QUALIFICATION APPLICANT
DCA USE ONLY
Agency File Number(s)_____________________________
New Applicant File Number_________________________
CII Number______________________________________
DOJ USE ONLY
CII Number_______________________________________
_________________________________________________
Agency File Number(s)______________________________
Please print clearly. Use ball point pen. Be sure all copies are legible.
FAILURE TO PROVIDE COMPLETE INFORMATION WILL RESULT IN REJECTION OF APPLICATION.
Currently/Previously Current/Previous
APPLICATION FOR
(Check appropriate block)
Licensed as: License Number(s) Exp. Date
New Application - FQC
Annual Renewal Private Investigator_______________________________________________
Private Patrol Operator____________________________________________
Firearms Qualification Number
Alarm Company Operator__________________________________________
Security Guard___________________________________________________
Expiration Date
Alarm Agent_____________________________________________________
APPLICANT INFORMATION
_____________________________________________________________ ________________________________________
Name (last, first, middle) Other names used
_______________________________________________________________________________________________________
Address (number, street, city, state, zip code)
Date of Birth
/ /
Place of Birth Sex Hair Eyes Weight Height
___
____________________________________________________________________________________ _________________________________________________________________
Social Security Number Driver’s License Number
CERTIFICATION
“I declare under penalty of perjury (Sections 126 and 672 PC) that all statements made by me on this application
are true and complete.”
Signature of applicant Date
DOJ Use Only
FIREARM STATUS
Application rejected – reason: ________________________________________________________________
Not prohibited
Prohibited: Lifetime Limited – expiration date / /
Other ____________________________________________________________________________________
Analyst Date / /
BCIA 4040
WHITE – BSIS File; YELLOW – DOJ File; PINK – DOJ Response; BLUE – DOJ/FAP File
(Rev. 1/95)
