NOTICE: This Application is a two-sided, one page document.
If Internet form, print Page 1, return to printer and print Page 2 on reverse side.
(1) NAME Last First Middle
(5) DATE OF BIRTH (6) AGE (7) PLACE OF BIRTH City State (8) COUNTY OF RESIDENCE
(9) MUN. CODE NO.
(2) SOCIAL SECURITY NUMBER
(10) SEX HEIGHT WEIGHT HAIR EYES RACE
(4) HOME PHONE NUMBER
(15) SBI NUMBER
(13) FORMER EMPLOYER'S PHONE NO.
S.P. 232 (Rev. 06/09)
(17) Are you subject to any court order issued pursuant to Domestic Violence? If yes, explain.
(18) Have you ever been adjudged a juvenile delinquent? If yes, list date(s), place(s), and offense(s).
(21) Do you suffer from a
physical defect or disease?
(20) Have you ever been convicted of a crime in New Jersey or a criminal offense in another jurisdiction where you could have been
sentenced to more than six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and crime(s).
(19) Have you ever been convicted of a disorderly persons offense in New Jersey or any criminal offense in another jurisdiction where you
could have been sentenced up to six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and offense(s).
(23) Are you an alcoholic?
(11) FORMER LAW ENFORCEMENT EMPLOYER (12) ADDRESS OF FORMER EMPLOYER
(16) Have you ever been convicted of any domestic violence offense in any jurisdiction which involved the elements of (1) striking, kicking,
shoving, or (2) purposely or attempting to or knowingly or recklessly causing bodily injury, or (3) negligently causing bodily injury to another
with a deadly weapon? If yes, explain.
(29) SIGNATURE OF APPLICANT (30) DATE OF APPLICATION
The disclosure of my Social Se cu ri ty num ber is voluntary.
Without this number, the pro cess ing of my application may be
de layed. This number is used for document track ing pur pos es
only and is con sid ered con fi den tial.
(3) RESIDENCE ADDRESS Street City State Zip Code
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
STATE OF NEW JERSEY
Initial Application For a Retired Law Enforcement Officer
Permit to Carry a Handgun
Applicant: Complete ONLY PART 1 of this application and mail entire two page application to NJSP Firearms Investigation Unit - RPO, P.O. Box 7068,
West Trenton, NJ 08628-0068. If you reside in New Jersey, enter your municipal code in block 9. If your retirement is a result of service with more than
one agency, list the most recent agency information in block 11 and attach a listing of all agencies with which you earned retirement credit. Include full
contact information for each agency. Failure to properly complete this application may result in a delay in issuing a permit to carry.
(14) DRIVER'S LICENSE NUMBER & STATE
(22) If answer to question 21 is yes, does this make it unsafe for you to handle firearms? If not, explain.
Yes
No
(24) Have you ever been confined or committed to a mental institution or hospital for treatment or
observation of a mental or psychiatric condition on a temporary, interim, or permanent basis? If yes, give
the name and location of the institution or hospital and the date(s) of such confinement or commitment.
Yes
No
(25) Are you dependent
upon the use of a narcotic(s)
or other controlled
dangerous substance(s)?
Yes
No
(27) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, permit to carry a handgun or any other firearms
license or application refused or revoked in New Jersey or any other state? If yes, explain.
Yes
No
(26) Have you ever been attended, treated or observed by any doctor or psychiatrist or at any hospital or
mental institution on an inpatient or outpatient basis for any mental or psychiatric condition? If yes, give the
name and location of the doctor, psychiatrist, hospital or institution and the date(s) of such occurrence.
Yes
No
Part 1
Page 1
(28) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of force
and violence, either to overthrow the Government of the United States or of this State, or which seeks to deny others their rights under the
Constitution of either the United States or the State of New Jersey? If yes, list name and address of organization(s).
Yes
No
PRINT OR TYPE ALL INFORMATION
Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c.
