Application for Duplicate Firearms Purchaser Identification Card
(3) Date of Birth
Month Day Year
IDENTIFICATION CARD NUMBER
STATE OF NEW JERSEY
(1) Last Name ( If female, include maiden) First Middle (2) Resident Address (Number - Street - City - State - Zip)
(4) Age (5) Distinguishing Physical Characteristics (Marks, Scars, Tattoos) (6) U.S. Citizen
Yes No
(7) Social Security Number
(8) Sex Height Weight Eyes Race Hair Complexion (9) Driver's License Number & State
(11) Address Appearing on Former Card
(13) Have you ever been adjudged
a juvenile delinquent?
If Yes, List Date(s) Place(s) Offense(s)
(14) Have you ever been convicted
of a disorderly persons offense,
that has not been expunged or
sealed?
(15) Have you ever been convicted
of a criminal offense, that has
not been expunged or sealed?
(16) Have you ever had a firearms
purchaser identification card,
permit to purchase a handgun,
or permit to carry a handgun
refused or revoked?
If Yes, By Whom? When? Where Why?
(17) Have you ever had an
Employee of Firearms Dealer
License refused or revoked?
(18) Are you an Alcoholic? (19) 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
(20) Are you dependent upon the
use of any narcotic or other
controlled dangerous substance?
(22) 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 conditions? If Yes, give the name &
location of the doctor, psychiatrist, hospital or institution and the date(s) of such occurrence.
(21) Are you now being treated for
a drug abuse problem?
(23) Do you suffer from a physical
defect or sickness?
(12) N.J. Firearms ID Card/ SBI number
(24) If answer to question 2
3 is yes, does this make it unsafe for you to
handle firearms? If not, explain.
(25) Are you subject to any court order issued pursuant to Domestic
Violence? If yes, explain.
(26) Have you ever been convicted of any domestic violence 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 weapon? If Yes, explain.
A Request for a Criminal History Name Check (SBI 212A) must accompany
this application along with the required fee payable to "Division of State
Police SBI." Application must be made to the Chief of Police, in the
municipality in which you reside or to the Superintendent in all other cases.
I hereby certify that the answers given on this application are
complete, true and correct in every particular. I realize that if any of
the foregoing answers made by me are false, I am subject to
punishment.
(28)
Signature of Applicant Date of Application
(The disclosure of my social security number is voluntary. Without this number, the processing of my
application may be delayed. This number is considered confidential.)
Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c.
STS-3 (Rev 09/06)
This form is prescribed by
the Superintendent for use
by applicants for duplicate
Firearms I.D. Cards. Any
alteration to this form is
expressly forbidden.
(27) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of violence, either to overthrow
the government of the United States or of this State, or to deny others of 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) here:
All persons wishing to obtain a duplicate Firearms Purchaser Identification Card are required to
complete this application form.
APPROVED
This Day of , 20
DISAPPROVED
Reason for Disapproval
A. CRIMINAL RECORD
B. PUBLIC HEALTH SAFETY AND WELFARE
C. MEDICAL, MENTAL OR ALCOHOLIC BACKGROUND
D. NARCOTICS/ DANGEROUS DRUG OFFENSE
E. FALSIFICATION OF APPLICATION
F. DOMESTIC VIOLENCE
G. OTHER (SPECIFY)
GRANTED ON
APPEAL
APPLICANT: DO NOT WRITE BELOW THIS SPACE
Check Appropriate Block(s)
Application to replace lost or stolen Identification Card Application for change of address on Identification Card
Application to replace mutilated Identification Card Application for change of sex on Identification Card
Application for change of name on Identification Card
List former name here and attach copy of marriage license or court order
(10) Home Telephone
Yes
No
If Yes, List Date(s) Place(s) Offense(s)
Yes
No
If Yes, List Date(s) Place(s) Offense(s)
Yes
No
Yes
No
If Yes, By Whom? When? Where Why?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Signature Title
Department of Police
APPLICANT: DO NOT WRITE BELOW THIS SPACE
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