NOTICE AND STATEMENT
OF APPLICANT
INSTRUCTIONS:
1. Please sign this form in the two areas provided below.
2.
Mail form to:
NOTICE
The purpose of this notice is to advise that all applications for registrations/permits are
individually checked for convictions of any crime other than traffic violations.
Your failure to truthfully disclose any such convictions, either for yourself or your spouse may
result in the denial of your application for registrations/permits.
Similarly, your failure to provide all of the details of ANY conviction, such as the date of the
conviction, the offense of which you were convicted, the court location where you were
convicted and the disposition made by the court location where you were convicted and the
disposition made by the court in your case – i.e., 30 days - $50.00 fine, probation, etc. will also be
cause for denial of the registration/permit.
In addition, any falsification or untruthful answer to any other question on the application may
result in a denial of the registration/permit.
Please sign this form where indicated below.
I hereby acknowledge that I have read the foregoing notice.
Printed Name of Applicant
Signature of Applicant
Date
STATEMENT OF APPLICANT
BY THE ACCEPTANCE OF ANY REGISTRATION/PERMIT issued pursuant to this application:
I agree to abide by t
he applicable Regulations.
I HEREBY CERTIFY that I have read the foregoing application and affirm that every statement
contained therein is TRUE, COMPLETE AND CORRECT. I understand that if I misstate or omit
any fact, I am subject to the penalties provided by law and by the above-mentioned applicable
regulations.
I HE
REBY AUTHORIZE the to investigate any and all records
concerning my background, including – but not limited to – any criminal convictions. I
FULLY UNDERSTAND the preceding WAIVER.
Printed Name of Applicant
Signature of Applicant
Date
