Nicolet Area Technical College, REV. 11/2016 Page 2 of 2
9. Are you an unlawful user of, or addicted to, marijuana, or any
depressant, stimulant, or narcotic drug, or any other controlled
substance?
10. Have you ever been adjudicated mentally defective (which includes
having been adjudicated incompetent to manage your own affairs) or
have you ever been committed to a mental institution?
11. Have you been discharged from the Armed Forces under
dishonorable conditions?
12. Have you been convicted in any court of a misdemeanor crime of
domestic violence?
13. Have you ever renounced your United States citizenship?
14. Are you an alien illegally in the United States?
15. Are you a United States citizen?
I certify that all statements on this form are true. I understand that if I knowingly make a false
statement, I may be subject to penalties, fines, and/or imprisonment under WI Statutes and/or
Federal Law. (WARNING: TRANSFER TO MINORS, FELONS AND PROHIBITED PERSONS. It is illegal for anyone to
provide o
r assist in providing any firearm to a minor, except under certain conditions as set forth in the Wisconsin statutes,
and under any circumstances to provide or assist in providing any firearm to a convicted felon or any other person prohibited
by law from possessing a firearm under s 941.29.)
Signature:_______________________________________________________________
Telephone Number: ________________________ Date________________________
DEFINITIONS
Under indic
tment or information or convicted in any court: An indictment, information, or conviction in any
Federal, State, local, or foreign court.
Misdemeanor Crime of Domestic Violence: A Federal, State, or local offense that is a misdemeanor under Federal
or State law and has, as an element, the use or attempted use of physical force, or the threatened use of a deadly
weapon, committed by a current or former spouse, parent, or guardian of the victim, by a person with whom the
victim shares a child in common, by a person who is cohabiting with, or has cohabited with the victim as a spouse,
parent, or guardian, or by a person similarly situated to a spouse, parent, or guardian of the victim. The term includes
all misdemeanors that have as an element the use or attempted use of physical force or the threatened use of a
deadly weapon (e.g., assault and battery), if the offense is committed by one of the defined parties.
PRIVACY ACT INFORMATION
Disclosure of the individual’s social security number is voluntary. The number may be used to verify the individual’s
identity.
