Fillable Special Licensing and Firearms Unit (Pursuant to P.A. (State of Connecticut/Department of Administrative Services)

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Special Licensing and Firearms Unit (Pursuant to P.A. (State of Connecticut/Department of Administrative Services)

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BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

DESPP-417-C (Rev. 10/02/13) An Affirmative Action/Equal Employment Opportunity Employer Page 1 of 2

Special Licensing and Firearms Unit

(Pursuant to P.A. 13-3 and P.A. 13-220)

Official Use Only

Certificate Number: A___________

Application for Ammunition Certificate

1. Please type or print legibly (Illegible applications will be returned).

2. When you appear to have your photograph and signature captured, submit a $35.00 fee, payable by check

or money order, to “Treasurer, State of Connecticut” or exact cash payment, with the completed

application, to the Special Licensing and Firearms Unit located at 1111 Country Club Road, Middletown,

Connecticut 06457-2389.

Name: (Last, First, Middle Initial)

Address: (Number, Street, City/Town and Zip Code)

Date of Birth:

Sex:

Race:

Social Security Number (Optional, but will help prevent misidentification ):

Motor Vehicle Operator’s License Number:

Issuing State:

Height:

Weight:

Have you been convicted of a felony? Yes No

Have you ever been convicted of a misdemeanor crime of domestic/family violence?

Yes No

Have you ever been convicted of any of the following misdemeanors? Yes No

If yes, check all that apply.

Illegal Possession of controlled or hallucinogenic substances (C.G.S. § 21a-279(c))

Assault of an elderly, blind, disabled or pregnant person or a person with intellectual disability in the 3

(C.G.S. § 53a-61a)

Criminally negligent homicide (C.G.S. § 53a-58) Unlawful restraint 2

(C.G.S. § 53a-96)

Assault in the 3

(C.G.S. § 53a-61) Riot 1

(C.G.S. § 53a-175)

Threatening 2

(C.G.S. § 53a-62) Riot 2

(C.G.S. § 53a-176)

Reckless endangerment 1

(C.G.S. § 53a-63) Inciting to riot (C.G.S. § 53a-178

Stalking 2

(C.G.S. § 53a-181d)

Have you been discharged from custody within the preceding twenty (20) years after having been found not guilty of a crime by

reason of mental disease or defect pursuant to C.G.S. § 53a-13?

Yes No

Have you been confined in a hospital for a persons with psychiatric disabilities within the preceding sixty (60) months by order

of a Probate Court? Yes No

Have you been voluntarily admitted to a hospital for persons with psychiatric disabilities within the preceding six (6) months for

reasons other than solely for alcohol or drug dependence? Yes No

STATE OF CONNECTICUT

DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION

DIVISION OF STATE POLICE

DESPP-417-C (Rev. 10/02/13) An Affirmative Action/Equal Employment Opportunity Employer Page 2 of 2

Are you the subject of an active restraining or protective order issued by a court, after notice and an opportunity to be heard has

been provided to you, in a case involving the use, attempted use or threatened use of physical force against another person?

Yes No

Are you the subject of a court issued risk warrant to seize firearms pursuant to C.G.S § 29-38c(d)?

Yes No

Are you an alien illegally or unlawfully in the United States? Yes No

Are you prohibited from shipping, transporting or receiving a firearm pursuant to 18 USC 922(g)(4)?

Yes No

I understand that any false statement herein, which I do not believe to be true and which is intended to mislead a public

servant in the performance of his or her official function, is punishable by law (See C.G.S. § 53a-157b). Violation of

Section 53a-157b constitutes a Class A Misdemeanor. I further understand that any statement in this application that

is determined to be false or inaccurate shall constitute grounds for the denial of such application. If approved before the

facts are known, such approval shall be void if based on a false or inaccurate statement. My signature below attests to

the accuracy, completeness and to the truth of all information supplied on this application:

I declare, under the penalties of false statement, that the answers to the above are true and correct.

SIGNED: Dated:

Appendix A, Large Capacity Magazine(s) Declaration Form, DESPP-788-C, is available at ct.gov/despp, or may be

obtained at the Department of Emergency Services and Public Protection, Special Licensing and Firearms Unit.

For Official Use Only:

Date of in-state criminal history check:

Certificate Number: A ______

Processed by: ______

Date:

Visit the department’s website at ct.gov/despp

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Completed 13 August 2020

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