Fillable MINNESOTA UNIFORM FIREARM APPLICATION PERMIT TO CARRY A PISTOL 2015

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MINNESOTA UNIFORM FIREARM APPLICATION PERMIT TO CARRY A PISTOL 2015

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DATA PRACTICES ADVISORY
MINNESOTA UNIFORM FIREARM APPLICATION
PERMIT TO CARRY A PISTOL
(TYPE OR PRINT ONLY)
THIS APPLICATION MUST BE SUBMITTED IN PERSON
CHECK TYPE
NEW
RENEWAL
PERSONAL DATA CHANGE
REPLACEMENT
EMERGENCY
NOTE: PERSONAL DATA CHANGE/
REPLACEMENT APPLICANTS NEED ONLY
COMPLETE REQUIRED PERSONAL DATA
AND SIGN WHERE INDICATED.
NOTICE TO APPLICANT: An incomplete application will be denied. If an applicant is found to have knowingly falsified this
application or omitted pertinent information that person may be subject to criminal prosec
ution. The waiting period will begin on the
date that this application is fully completed and submitted.
The Minnesota Data Practices Act requires you be advised of the following:
As an applicant for a permit to carry a pistol, you are being asked to provide private data about yourself that will be used to check
various databases to determine your eligibility to possess a firearm.
You may refuse to provide this data. If you refuse, the background check cannot be completed and your application will not be
processed. Providing the data will permit the background check to be completed. The result of the check may be either affirmative or
negative. The data you provide may be shared with other criminal justice agencies, via court order or as authorized or required by
law.
I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.
SIGNATURE: DATE:
REQUIRED PERSONAL DATA
NAME (LAST, FIRST, MIDDLE, JR/SR): BIRTH DATE: PHONE NO.:
MAIDEN NAME (if applicable) OR OTHER NAMES YOU HAVE USED:
PRESENT RESIDENCE ADDRESS:
CITY/TOWNSHIP (if applicable):
COUNTY:
ZIP CODE:
SEX:
HEIGHT:
WEIGHT:
EYE COLOR:
HAIR COLOR:
STATE:
DRIVER’S LICENSE, STATE ID OR PASSPORT NUMBER:
DISTINGUISHING PHYSICAL CHARACTERISTICS (INCLUDING SCARS, MARKS, TATTOOS, ETC.):
PREVIOUS RESIDENCES (PAST 5 YEARS)
FROM (Mo/Yr) – TO (Mo/Yr)
CITY
TOWNSHIP (if applicable)
COUNTY
STATE
Rev. 2015 1
DATA PRACTICES ADVISORY
AUTHORIZATION FOR RELEASE OF HUMAN SERVICES DATA FOR BACKGROUND CHECKS
NAME (LAST, FIRST, MIDDLE, JR/SR): BIRTH DATE: PHONE NO.:
MAIDEN NAME (if applicable) OR OTHER NAMES YOU HAVE USED:
PRESENT RESIDENCE ADDRESS:
CITY/TOWNSHIP (if applicable):
COUNTY:
ZIP CODE:
TO: Minnesota Department of Human Services or a similar government agency in another state that maintains data about civil
commitments
By signing this Authorization for Release of Data I am giving the Minnesota Department of Human Services or a similar government
agency in another state permission to release the following types of data about me to the named law enforcement agency. I
understand this data will be used by the law enforcement agency as part of a background check to determine whether I am eligible for
a permit to carry, eligible to renew a permit to carry, or eligible for a permit to purchase a firearm.
The data I am asking to be released would indicate whether I have been:
Committed by a court as mentally ill, developmentally disabled or mentally ill and dangerous to the public
Committed by a court as chemically dependent
Found incompetent to stand trial or found not guilty by reason of mental illness
A peace officer informally admitted to a treatment facility for chemical dependency
The data
is to be released to the listed law enforcement agency:
AGENCY NAME:
AGENCY ADDRESS:
AGENCY CONTACT PERSON AND PHONE NUMBER:
I understand that by signing this form I am requesting the data listed be sent to the law enforcement agency listed. I may cancel this
consent at any time by writing to the Minnesota Department of Human Services or government agency in another state. If data has
already been released based on this consent, my request to cancel the release will not work for that data.
I understand when the data is s
ent to the law enforcement agency, the data could be redisclosed as allowed under federal and state
law. If I choose not to sign this consent form, I may not be able to receive a permit.
This consent will end five years from the date any permit is issued unless I indicate an earlier date or event here:
SIGNATURE:
DATE:
For Law Enforcement Use Only – Permit Issue Date:
Rev. 2015 2
RESTRICTIONS
The following restrictions apply to the possession of firearms, to purchase/transfer permits, and reports of transfer for handguns and
semiautomatic military-style assault weapons. Individuals with restrictions shall not be entitled to possess a pistol or any other firearm. The
legal basis for the restrictions may be found in federal law (18 United States Code § 922) or Minnesota law (Minnesota Statutes, §§ 253B.02,
624.712, 624.713. 624.7131 or 624.714).
•
Must be at least 21 years old to purchase a handgun or handgun ammunition from a federally licensed dealer.
•
Must be at least 18 years old to purchase a semi-automatic assault rifle.
•
Must not have been convicted, adjudicated delinquent or convicted as an extended jurisdiction juvenile of a crime of violence in Minnesota or
elsewhere unless civil rights have been restored and during that time you have not been convicted of any other crime of violence.
NOTE: This lifetime prohibition on possessing, receiving, shipping, or transporting firearms for persons convicted or adjudicated
delinquent of a crime of violence applies only to offenders who are discharged from sentence or court supervision for a crime of
violence on or after August 1, 1993.
•
Must not have been charged with a crime of violence or placed in a pretrial diversion program by the court before disposition until you have
completed the diversion program and the charge of committing the crime of violence has been dismissed.
•
Must not have been convicted of fifth-degree assault as defined in Minnesota Statutes, §609.224 or assault as defined in Minnesota Statutes,
§609.2242 or a similar offense in another state where the victim was a family or household member since August 1, 1992. Additional restrictions
apply.
• Must not have been convicted in any court of a misdemeanor crime of domestic violence as defined in 18 United States Code section 922(g)(9).
Federal law prohibits the possession of a firearm for anyone convicted in any court of a qualified misdemeanor crime of domestic violence.
• Must not be subject to a court order that (1) was issued after a hearing of which you had actual notice and at which you had an opportunity to
participate; (2) restrains you from harassing, stalking, or threatening an intimate partner, a child of an intimate partner, or your own child, or
engaging in other conduct that would place an intimate partner in a reasonable fear of bodily injury to that person or a child; and (3) includes a
finding that you represent a credible threat to the physical safety of such intimate partner or child or by its terms explicitly prohibits the use,
attempted use, or threatened use of physical force against such intimate partner or child that would reasonably be expected to cause bodily injury.
• Must not be an unlawful user of any controlled substance as defined in Chapter 152 of Minnesota Statutes.
• Must not be a person who is or has ever been committed by a judicial determination for treatment for the habitual use of a controlled substance as
defined in Minnesota Statutes, §§ 152.01 and 152.02, unless the person's ability to possess a firearm has been restored under Minnesota Statutes,
§624.713, subdivision 4 and must not have been convicted in Minnesota or elsewhere of a misdemeanor or gross misdemeanor violation of
Chapter152 of Minnesota
Statutes, unless three years have elapsed since the date of conviction and duri
ng that time the person has not
been convicted of any other such violation of Chapter 152 of Minnesota Statutes or a similar law of another state.
• Must not have been committed to a treatment facility in Minnesota or elsewhere as chemically dependent unless you have completed treatment or
your civil rights to possess a firearm have been restored.
• Must not have been judicially committed to a treatment facility in Minnesota or elsewhere as "mentally ill," "developmentally disabled” or “mentally
defective," or "mentally ill and dangerous to the public."
• Must not be a peace officer who has been informally admitted to a treatment facility for chemical dependency unless you possess a certificate from
the head of the treatment facility discharging or provisionally discharging you from that facility.
•
Must not have been conv
icted
in Minnesota or elsewhere of a crime punishable by imprisonment for more than one year (other than for offenses
pertaining to
ant
itrus
t violations,
u
nfair
t
r
ade practices,
restraints of trade, or
similar offenses
relating to the regulation of business practices) unless
your civil rights have been restored or the conviction has been pardoned, expunged, or set aside.
• Must not be a fugitive from justice as a result of having fled from any state to avoid prosecution for a crime or to avoid giving testimony in any
criminal proceeding.
• Must not be an alien who is illegally or unlawfully in the United States.
• Must not have been discharged from the armed forces of the United States under dishonorable conditions.
• Must not have renounced your United States citizenship.
•
Must not have
been convicted of a gross misdemeanor level crime committed for the benefit of a gang (§609.229); assault motivated by bias
(§609.2231, subd. 4); false imprisonment (§609.255); neglect or endangerment of a child (§609.378); burglary in 4th degree (§609.582 subd. 4);
setting a spring gun (§609.665); riot (§609.71) or harassment and stalking (§609.749), unless three years have elapsed since the date of conviction
and during that time you have not been convicted of any other violation
of these sections. (All references are to Minnesota Statutes.)
• Must not be under a qualified domestic abuse restraining order as defined in 18 United States Code section 922 (g)(8) or (9) as amended through
March 1, 2014.
Rev. 2015 3
CHANGE OF ADDRESS/LOSS OR DESTRUCTION OF PERMIT
If card is lost or destroyed, permit holder must provide a notarized statement that the card has been lost or destroyed.
Failure to provide notification as required by this subdivision is a petty misdemeanor.
Within 30 days after changing permanent address, or within 30 d
ays of having lost or destroyed the permit card, the permit holder
must notify the issuing sheriff’s office of the change, loss, or destruction.
RESTRICTIONS
The following statutes describe persons that are prohibited from possessing a firearm:
• Minnesota Statutes, §518B.01, subdivision 14 - Violation of an Order for Protection.
•
Minnesota Statutes, §609.224, subdivision 3 - Assault in the 1
st
through 5
th
degree with firearms.
• Minnesota Statutes, §609.2242, subdivision 3 - Domestic assaults with firearms.
• Minnesota Statutes, §609.749, subdivision 8 - Harassment; Stalking; Firearms.
•
Minnesota Statutes, §624.713 - Certain persons not to possess firearms.
• Minnesota Statutes, §624.719 - Possession of a firearm by non-resident alien.
• Minnesota Statutes, §629.715, subdivision 2 - Surrender of firearms as condition of release.
• Minnesota Statutes, §629.72, subdivision 2 - Judicial review that prohibits person from possessing a firearm.
• Minnesota Statutes, §299C.091 - Listed in the criminal gang investigation system.
Note: Federal laws, not listed herein, may also prohibit possession of a firearm for certain persons.
I HEREBY STATE TO THE BEST OF MY KNOWLEDGE AND BELIEF THAT I AM NOT PROHIBITED BY LAW FROM
POSSESSING A FIREARM.
SIGNATURE: DATE:
FOR OFFICE USE ONLY
The Applicant must submit the following items with this application:
A completed application form, signed and dated by the Applicant;
An accurate photocopy of a certificate, affidavit, or other document that is submitted as the Applicant’s evidence of training in
the safe use of a pistol that meets the requirements of Minnesota Statutes, §624.714;
An accurate photocopy of the Applicant’s current driver’s license, state identification card, or the photo page of the Applicant’s
passport.
In addition to the other application materials, a person who is otherwise ineligible for a permit due to a criminal conviction but
who has obtained a pardon or expungement setting aside the conviction, sealing the conviction, or otherwise restoring
applicable rights, must submit a copy of the relevant order.
NOTICE OF REVOCATION
Permit, if granted, shall be void at the time the holder becomes prohibited from possession of a pistol under Minnesota Statutes, in
which event the holder must immediately return the permit to the issuing sheriff’s office.
DENIAL
This application is denied based on the following reason(s):
Sheriff’s Office
4
Rev. 2015
MINNESOTA UNIFORM FIREARM APPLICATION
PERMIT TO CARRY A PISTOL
RECEIPT
CHECK TYPE
NEW
RENEWAL
PERSONAL DATA
CHANGE
REPLACEMENT
EMERGENCY
I HEREBY ACKNOWLEDGE ACCEPTANCE OF THE PERMIT TO CARRY APPLICATION OF:
(Name of Applicant)
Date:
ved:
Time:
Amount Recei Form of Payment:
Signature of person accepting application Issuing Sheriff’s Office
This receipt DOES NOT constitute a permit to carry a pistol.
Rev. 2015 5
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Completed 9 December 2019

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