FIREARM APPLICATION QUESTIONNAIRE
Please answer the questions below by WRITING YOUR INITIALS on the line under “yes” or “no.”
YES NO
1. Are you a fugitive from justice? [HRS §134-7(a) and 18 U.S.C. §922(g)(2)] ___ ___
2. Are you under indictment or information, or have waived indictment, or bound over
to the circuit court, in this State or elsewhere, for a crime punishable by
imprisonment for a term exceeding one year? [HRS §134-7(b) and 18 U.S.C. §922(n)]
___ ___
3. Have you been convicted, in this State or elsewhere, of a crime punishable by
imprisonment for a term exceeding one year? [HRS §134-7(b) and 18 U.S.C. §922(g)(1)]
___ ___
4. Are you under indictment or information, or have waived indictment, or bound over
to the circuit court, in this State or elsewhere, for any crime of violence or for the
illegal sale of any drug? [HRS §134-7(b)]
___ ___
5. Have you been convicted, in this State or elsewhere, for any crime of violence or
for the illegal sale of any drug? [HRS §134-7(b)]
___ ___
6. Are you or have you been under treatment or counseling for addiction to, abuse of,
or dependence upon any dangerous, harmful, or detrimental drug, intoxicating
compound, or intoxicating liquor, or controlled substance? [HRS §134-7(c)(1)]
If yes, Include name of treating physician: ________________________________
___ ___
7. Are you an unlawful user of or addicted to any controlled substance? [18 U.S.C.
§922(g)(3)]
If yes, Include name of treating physician: ________________________________
___ ___
8. Are you authorized to utilize marijuana for medical purposes? [18 U.S.C. §922(g)(3)]
If yes, please provide expiration date of authorization:______________________
and the state which issued authorization: __________________________
___ ___
9. Have you been acquitted of a crime on the grounds of mental disease, disorder, or
defect? [HRS §134-7(c)(2)]
If yes, Include name of treating physician: ________________________________
___ ___
10. Have you been adjudicated as a mental defective or have been committed to any
mental institution?
[18 U.S.C. §922(g)(4)]
If yes, Include name of treating physician: ________________________________
___ ___
11. Have you been diagnosed as having a behavioral, emotional, or mental
disorder(s)? [HRS §134-7(c)(3)]
If yes, Include name of treating physician: ________________________________
___ ___
12. Are you or have you been under treatment for organic brain syndrome(s)?
[HRS §134-
7(c)(3)]
If yes, Include name of treating physician: ________________________________
___ ___
