PD
USE
ONLY
FTN:
THE
COMMONWEALTH
OF
MASSACHUSETTS
EXECUTIVE OFFICE
OF
PUBLIC SAFETY
AND
SECURITY
Department
of
Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
UC#:
------
mass.gov/cjis I
TTY:
617-660-4606
*You
must
submit
this
form
to
your
local
police
department*
MASSACHUSETTS RESIDENT LTC/FID/MACHINE GUN APPLICATION
FOR NEW/RENEWAL OF A FIREARMS IDENTIFICATION CARD
OR
LICENSE TO
CARRY
FIREARMS OR LICENSE TO POSSES A MACHINE GUN (M.G.L
c.140,
§§
1298,
131)
CHECK ONE:
New Applicant*
Renewal - Most Recent License to Carry/FID Number:
*NOTE:
If
application is
for
a first firearms identification card
or
license to carry firearms, a copy
of
the Firearms Safety Certificate or
Hunter
Safety Course Certificate must be attached, unless exempt by statute.
If
this is a renewal application, a lost/stolen firearms
affidavit must be submitted.
LICENSE APPLICATION TYPE (Check Only One):
Firearms Identification Card - Restricted (self-defense spray)
Firearms Identification Card
License to Carry
License to Possess a Machine Gun
Gun Club License (Only the Colonel
of
the State Police can issue a club license)
EXCEPT FOR SIGNATURE, PRINT OR TYPE
ALL
REQUESTED INFORMATION:
Last Name First Name Middle Name
Suffix
Residential Address
City
State Zip Code
Telephone Number
Mailing Address
City State Zip Code Telephone Number
Date
of
Birth
Place of Birth (City, State, Country)
Mother's First Name
Mother's Maiden Name Father's First Name Father's Last Name
Height Weight Build
Complexion Hair Color Eye Color
Occupation
Social Security Number (Optional) Drivers License Number
Employed By
Business Address
City/Town
State Zip
Telephone Number
LTC-FID Application-Revised May 2015
Page 1
of4
ANSWER THE FOLLOWING QUESTIONS COMPLETELY AND ACCURATELY:
1.
Are you a citizen
of
the United States?
DYES
D
NO
If lawful permanent resident alien, give
green card number and resident date
If naturalized, give date, place
and naturalization number
Green
Card Number
Date
Resident Since (date)
Place
Naturalization No.
2.
Have you ever renounced your U.S. citizenship?
DYES
D
NO
3.
4.
5.
6.
7.
8.
9.
What
is
your
age?----
(You must be
21
to apply
fora
LTC,
18
to apply
fora
FID card, or 14 to 17with
submission
of a
certificate
of
parent
or
guardian
granting
permission
to
apply
for
a FID
card
or
FIO
card
- Restricted).
Have you ever been arrested or appeared in court
as
a defendant for any criminal offense?
Are you the subject of any pending criminal charges?
Have you ever been convicted
of
a felony?
Have you ever been convicted
of
the unlawful use, possession, or sale
of
controlled substances
as defined in M.G.L.
c.
94C, § 1?
Have you ever been convicted
of
a violent crime or a crime
of
domestic violence?
10. Have you ever been convicted as an adult or adjudicated a youthful offender or delinquent child
in any state or federal jurisdiction?
11. Are you now, or have you ever been the subject of a restraining order issued pursuant to M.G.
L.
c.
209A,
or
a similar order issued by another jurisdiction?
12. Are you
currently the subject
of
any outstanding arrest warrant in any state or federal jurisdiction?
13. Have you ever been committed to any
hospital
or
institution for mental illness,
or
alcohol
or
substance abuse?
13.
Has any firearms license issued under the laws
of
any state or territory ever been suspended, revoked,
or
denied?
14.
Have you been discharged from the armed forces
of
the United States under di.shonorable conditions?
15. Have you been the subject
of
an order
of
the probate court appointing a guardian or conservator?
DYES
DYES
DYES
DYES
DYES
DYES
DYES
DYES
DYES
DYES
DYES
DYES
If you answered "YES" to any
of
the questions 2-15, give details which must include dates,
circumstances and location; use a separate sheet
of
paper if necessary.
ONO
ONO
ONO
ONO
ONO
ONO
ONO
ONO
ONO
ONO
ONO
ONO
L TC·FID Application - Revised May 2015
Page-2of4
Have you ever used or been known by another name?
DYES
0
NO
If "YES", provide name and
explain:----------------------------------
Other than Massachusetts, in what state(s), territory(ies), or jurisdiction(s) have you lived?
Have you ever held a firearms license in any other state, territory or jurisdiction?
If "YES", when, where, and license number?
List the name and addresses
of
two references (as required by your licensing authority)
1.
Last Name First Name
Address City/Town
2.
Last Name First Name
Address
City/Town
Reason(s) for requesting the issuance
of
a card or license:
D Unrestricted D Target & Hunting D Sporting D Employment
DNONE
DYES
D
NO
State Zip
State Zip
Use lines below to indicate the reason(s)
you
are requesting the license;
use
a separate sheet of paper if necessary)
*WARNING* Any person who knowingly files
an
application containing false information shall
be
punished by a fine of not less than
$500 nor more than $1,000 or
by
imprisonment for not less than 6 months nor more than 2 years
in
a house of correction, or
by
both
such fine and imprisonment (M.G.L c.140,
§§ 1298(8),
131
(h)).
I declare the above facts are true and complete to the best of my knowledge and belief
and
I understand that any false answer(s)
will
be
just cause for denial or revocation of my license to carry firearms. I understand that filing
an
application that contains false
information
is
a criminal offense.
Signed under the penalties of perjury this
day of
day month
year
Signature of
Applicant:---------------------------------------
L TC-FID Application - Revised May 2015
Page-3
of4
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome