Fillable Mt Shasta Police Department CCW RENEWAL OR MODIFY/UP-DATE (City of Mt Shasta)

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Mt Shasta Police Department CCW RENEWAL OR MODIFY/UP-DATE (City of Mt Shasta)

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The Mt Shasta Police Department CCW RENEWAL OR MODIFY/UP-DATE (City of Mt Shasta) form is 3 pages long and contains:

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  • 18 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Mt Shasta

BROWSE CITY OF MT SHASTA (CA) FORMS

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Mt Shasta Police Department
303 N Mt Shasta Blvd - Mt Shasta CA 96067
(530)926-7540 - fax (530)926-3601
City
State
Zip
Mailing address (if different)
_____________________________________________________________________________
Street City State Zip
CCW RENEWAL OR MODIFY/UP-DATE INFORMATION FORM
Applicant Information (complete all)
Name: _________________________________________ Date of Birth:__________________
CII NUMBER: _____________________________ (found on current CCW)
HGT: _____________ WGT: _______________ EYE: _______________ HAIR: ______________
NEW ADDRESS (if applicable): ____________________________________________________
RESIDENCE ADDRESS:___________________________________________________________
_______________________________________________________________
_____________
PERSONAL PHONE NO’S (HOME)__________________________ CELL: ___________________
EMAIL ADDRESS: ________________________________________________
BUSINESS/EMPLOYER: _____________________________ OCCUPATION: ________________
BUSINESS PHONE NO: ______________________________
BUSINESS ADDRESS:
___________________________________________________________
Street City State Zip
NOTE: Standard CCW permit allows up to 3 firearms. All firearms need to be verified by the
Police Department before being added to permit.
Firearm Changes:
Manufacturer Serial # Model Caliber
____ Add ____ Delete __________________________________________________________
____Add ____ Delete __________________________________________________________
____Add ____ Delete __________________________________________________________
Additional Comments:
_
Firearms changes? ____Yes ____ No
In the past 2 years (24 months) have you been arrested? ____ Yes ____ No
(includes misdemeanor citations)
Named in a restraining order (TRO)? ____Yes ____ No
Received any type of counseling? ____Yes ____ No
Are you now or have you been under a doctor’s care for any psychiatric reason?
Have you been prescribed any medication? ____Yes ____
No
__ Yes ____ _
If you answer yes to any of the following questions, please explain in detail in the space provided on this page:
No
Signature of CCW holder: _______________________________________________________
**NOTE**
Under Section 12051(b) and 12051(c) of the California Penal Code, it can be a misdemeanor and/or a felony to
knowingly furnish false information on the CCW License Update/Renewal form and supplement to your original
application. Any false or misleading statements made on this form may also be cause for the revocation of your CCW
License and forfeiture of any fees paid.
CONCEALED WEAPON LICENSES RENEWAL APPROVED: DENIED:
BY: ___________________________________ TITLE:_____________________ DATE:__________________________
Please allow 2-4 weeks for processing
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MT SHASTA POLICE DEPARTMENT
CCW LICENSE RENEWAL
ATTESTATION PAGE
APPLICANT’S NAME:
I hereby attest to understanding and declare the following is true:
FEDERAL AVIATION REGULATION 121.583
US GOVERNMENT CODE TITLE 49, CHAPTER 26, SECTION 1472(1)
A concealed weapon license does not authorize a person to carry a firearm, tear gas, or any
dangerous weapon aboard commercial airlines. Further, a person must declare that he/she is
carrying such a firearm, tear gas, or dangerous weapon before entering the boarding area of an
air terminal where the security checks are made. Such violation can result in arrest by either
local or Federal authorities or both.
CONCEALED WEAPON PERMIT RESTRICTIONS AND CONDITIONS AGREEMENT
The following are restrictions and conditions that must be acknowledged and agreed to by the
applicant prior to the processing of the Concealed Weapon Permit application. While exercising
the privileges granted to the licensee under the terms of this license, the licensee shall not, when
carrying a concealed weapon:
• Consume any alcoholic beverage.
• Be under the influence of any medication or drug, whether prescribed or not.
• Refuse to show the license or surrender the concealed weapon to any peace officer
upon demand.
• Impede any peace officer in the performance of his duties.
• Present himself/herself as a peace officer to any person unless he/she is, in fact a
peace officer as defined by California law.
• Unjustifiably display a concealed weapon.
• Carry any concealed weapon not listed on the permit.
• Carry a concealed weapon at times or circumstances other than those specified in
the permit.
Any arrest for a felony or serious misdemeanor, including driving under the influence of alcohol
and/or drugs, is cause for invalidation of said permit. Any violation of these restrictions or
conditions invalidates said Concealed Weapon Permit and voids any further use of said permit
until reinstated by the Chief of Police.
HOLD HARMLESS AND IDEMNIFICATION AGREEMENT
I agree to hold the City of Mt. Shasta, it’s officers and employees including the Mt Shasta Police
Department and the Police Chief and his agents, harmless from and to indemnify them against
any and all liabilities including judgments, costs and attorney’s fees that may occur as the result
of my possession and/or use of the concealable firearms(s) named on the license, issued to me
by the Mt Shasta Police Department.
Licensee agrees that by accepting the Permit to Carry a Concealed Weapon, he/she will hold
harmless the City of Mt Shasta, the Mt Shasta Police Department and any and all officers or
employees thereof from any claim, suit, or judgment arising in any way of the exercise of the
right granted by any Concealed Weapon Permit issued to this applicant. (Government Code
818.4)
Signature of Applicant Date
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Mt Shasta Police Department CCW RENEWAL OR MODIFYUP-DATE (City of Mt Shasta)

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Completed 14 July 2020

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