Gun Purchase Form - New Jersey

Signature Title
Department of Police Municipal Code #
Yes
No
Yes
No
Yes
No
Check Appropriate Block(s)
Initial Firearms Purch aser Identification Card Change of name on Identification Card
Lost or Stolen Identification Card List former name and attach copy of marriage license or court order
Mutilated Identification Card
Change of Address on Identification Card
Change of Sex on Identification Card A pplication to Purchase a Handgun Quantity of Permits:
Application f or Firearm s P urchaser I dentificat ion C ard and/or Handgun Purchase Per m it
(22) If answer to question 21 is yes, does th is make it un safe for you to handle firearms? If not, exp lain.
(16) Have you ever been convicted of any domestic violence offense 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 dead ly weapon? If yes, explain.
(11) U.S. CITIZEN
Yes No
(24) Have you ever been confined or committed to a mental institution or hospital for treatment or observation of a
men t al or psychiatric conditi on on a tempo rary, interim, or perm anent basis? If yes, give the name and location of the
institution or hospital and the date(s) of such confinement or commitment.
(5) DATE OF BIRTH
(1) NAME Last ( If female, include maiden) First Middle
(3) RESIDENCE ADDRESS Number & Street City State Zip
(6) AGE (7) PLACE OF BIRTH City, State, Country
(2) SOCIAL SECURITY NUMBER
(9) SEX RACE HEIGHT WEIGHT HAIR EYES (10) DIST. PHYSICAL CHARACTERISTICS
(Marks, Scars, Tattoos)
(14) ADDRESS APPEARING ON FO RMER FIRE ARMS IDENTIFICA TIO N CARD (If Applicable) (15) N.J. FIREAR MS ID CARD/SBI NUMBER
(17) Are you subject to any court order issued pursuant to Domestic Violence? If yes, explain.
(4) HOME TELEPHONE
Yes
No
(8) DRIVER'S LICENSE NUMBER & STATE
(12) NAME OF EMPLOYER EMPLOYER'S ADDRESS & TELEPHONE (13) OCCUPATION
Yes
No
(18) Have yo u ever been adjudged a j uvenile delinquent? If yes, list date(s), place(s), and offen se(s).
Yes
No
(19) Have yo u ever been convicted of a disord erly persons offen se in New Jersey or any criminal of fense in another ju risdiction where you could have been
sentenced up to six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and offense(s).
Yes
No
(20) Have you ever been convicted of a crime in New Jerse y or a crim inal o ffe nse in another jurisd iction where yo u could h ave been sentenced to more than
six months in jail that has not been expunged or sealed? If yes, list date(s), place(s) and crime(s).
Yes
No
(21) Do you suffer from a
physical defect or disease?
Yes
No
Yes
No
(23) Are yo u an alco holic?
(25) Are yo u depend ent
upon the use of a narcotic(s)
or other controlled
dang erous substance(s)?
(26) Have you ever been attended, treated or obse rved by any doctor or psychiatrist or at any hospit al or mental
instit ution on an inpa tient or outpat ient basis for any mental or psyc hiatric condit ion? If yes, give the name and location
of the doctor, psychiatrist, hospi ta l or institu tion and the date(s) of such occurren ce.
Yes
No
(27) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, permit to carry a handgun or any other firearms license or
application refused or revoked in New Jersey or any other state? If yes, explain.
Yes
No
(28) Are you presently, or have you ever been a member of any organiza tion which advocates or approves the commission of acts of force and vi olence, either
to overthrow the Governme nt of the United S t ates or of this State, or which seeks to deny others 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).
Yes
No
S.T.S. 033 (Rev. 09/09)
(29) Names, Addresses and Telephone Num bers of two rep utable perso ns who are presently acquai nted w ith the applicant, other than relatives:
A.
B.
I hereby certify that the answers given on this application are complete, true and correct
in ever y pa rti cular . I re alize that if any of th e fore going ans wer s mad e by me ar e fals e, I
am sub j ect to punishment.
(30)
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 confident i al.)
Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c.
This Day of , 20
APPLICANT: DO NOT WRITE BELOW THIS SPACE
STATE OF NEW JERSEY
A non-refundable fee of $5.00 for a Firearms Purchaser Identification Card (Initial
Firearms Purchaser ID card only) and/or $2.00 for each Permit to Purchase a Handgun,
payable to the Superintendent of State Police or the Chief of Police in the municipality in
which you reside, must accompany this application.
IDENTIFICATION CARD/PERMIT NUMBER(S)
APPROVED
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
/
/
--
()
-
This form is prescribed by the Superintendent for use by applicants for Firearms Purchaser I.D. Cards & Handgun Purchas e Permits. Any alteration to this form is expressly forbidden.
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