SAN BERNARDINO COUNTY SHERIFF’S DEPARTMENT
655 East Third Street • San Bernardino, California 92415-0061 Post Office Box 569 • San Bernardino, California 92402-0569
JOHN McMAHON, SHERIFF-CORONER
San Bernardino County Sheriff’s Department
Pre-Background Interview Form CCW
Applicant: ___________________________________ Date: _____________________
Background Investigator: _________________________________________________
Please read and answer all questions. You are admonished to answer all questions completely and
truthfully. If you are dishonest in your answers, fail to fully answer any question, or misstate any
material facts, you may be denied a Concealed Weapons Permit.
If you answer “Yes” to any of the questions, you must provide an explanation on the comments page.
YES NO
1. Have you ever been denied a permit to carry a concealed weapon?..........................
2. Have you ever had a license to carry a concealed weapon revoked?.........................
3. Have you ever used another name or ever impersonated another person?...............
4. Are you currently taking any prescription medication on a regular basis
that would alter your moods or impair your judgment?...............................................
5. Have you ever been under the care of a psychiatrist or psychologist?......................
6. Have you ever been committed to a mental health facility either voluntarily
or involuntarily?................................................................................................................
7. Have you ever been found not guilty by reason of insanity?.......................................
8. Have you ever attempted suicide? …………………………………………………………..
9. Do you drink alcoholic beverages?.................................................................................
10. Have you ever been treated for or hospitalized for alcoholism, substance
abuse or drug addiction?..................................................................................................
11. Have you ever driven a vehicle while under the influence of alcohol or
drugs?.................................................................................................................................
12. Have you ever smoked, sold, grown or given marijuana to anyone?..........................
13. Have you ever used, possessed, or sold any controlled substance?.........................
14. Were you honorably discharged from the military?......................................................
15. Were you ever subject to a military court martial?........................................................
16. Were you ever in military confinement?.........................................................................
17. Has your driver’s license ever been suspended or revoked?......................................
18. Have you ever received a traffic citation, other than for parking?..............................
19. Have you ever been involved in a traffic accident?......................................................
20. Have you ever been involved in a hit and run accident? ………………………………...
21. Have you ever had a warrant issued for failure to appear/failure to
pay a fine?..........................................................................................................................
22. Have you ever been involved in a high speed pursuit in which you evaded
the police?..........................................................................................................................
REV 12/18
