STATE OF NEVADA                                                                    Initial Application
  APPLICATION FOR CONCEALED FIREARM PERMIT                 Renewal Application

Please type or print in black ink
Full Name (Last, First, and middle)								Home Phone
								Cell Phone
Physical Address (Number, Street, Apt #, City, State, Zip)
Mailing Address (If different from above)								Business Phone
Country of Citizenship				Place of Birth				Alien Number		Alien Expiration
Date of Birth	Race	Sex	Height	Weight	Hair	Eyes	Social Security #		Scars, Marks, Tattoos
Occupation				Name and Address of Employer
Answer each question and place a check mark over the appropriate choice
1.   Are there currently any outstanding warrants for your arrest?............................................................... Yes  No 2.   Have you ever been judicially declared mentally incompetent or insane?.......................................... Yes  No 3.   Have you ever been admitted to a mental facility?.................................................................................. Yes  No 4.   During the 5 years immediately preceding the date of this application, have you been convicted of driving under the influence of alcoholic or controlled substance in this or any other state?............................... Yes  No 5.   During the 5 years immediately preceding the date of this application, have you habitually used intoxicating liquor or narcotics to the extent that your normal faculties were impaired?.............................................. Yes  No 6.   During the 5 years immediately preceding the date of this application, have you been committed for treatment of the abuse of alcoholic beverages in this or any other state?....................................................................... Yes  No 7.   During the 5 years immediately preceding the date of this application, have you been committed for treatment of, or convicted of a crime related to controlled substance in this or any other state?................................. Yes  No 8.   During the 3 years immediately preceding the date of this application, have you been convicted of a crime involving the use or threatened use of force or violence punishable as a misdemeanor?.................   Yes  No 9.   Have you ever been convicted of a felony in this state or any other state?................................... ...... Yes  No 10.  During the 5 years immediately preceding the date of this application, have you been subject to any requirements imposed by a court as a  condition to the courts withholding the entry of judgment or suspension of a sentence, for the conviction of a felony?. ......................................................................................................... Yes  No 11.  Have you ever been convicted of a crime involving domestic violence or stalking in this or any other state?                              ……………………………………………………………………………………..…. Yes  No 12.  Are you currently subject to a restraining order, injunction or other order for protection against domestic violence in this or any other state?.................................................................................................................... Yes  No 13.  Are you currently on parole or probation for a conviction in this or any other state?......................... Yes  No 14.  Have you ever renounced your United States Citizenship?.................................................................. Yes  No 15.  Have you been dishonorably discharged from the Armed Forces?................................................... Yes  No

DO NOT WRITE IN THIS AREA.  POLICE AGENCY USE ONLY.

 (REV.7-08) PAGE 1 0F 3

STATE OF NEVADA
  APPLICATION FOR CONCEALED FIREARM PERMIT

THIS APPLICATION IS EXECUTED UNDER OATH.  FALSIFICATION OR MISREPRESENTATION OF ANY PART OR ANY PART OF ANY DOCUMENT SUBJECTS THE APPLICANT TO DENIAL OR REVOCATION OF THE PERMIT FOR WHICH THIS APPLICATION IS SUBMITTED.

Before me this day personally appeared _________________________________________________________________,
Name of Applicant

who being duly sworn, deposes and says:

I DO HEREBY SWEAR AND AFFIRM UNDER PENALTY OF PERJURY THAT THE FOLLOWING ASSERTIONS ARE TRUE AND CORRECT:

A.         The information contained in this application and all attached documents are true and correct to the best of my knowledge.

B.         I agree to immediately notify the issuing agency Concealed Weapons Unit if charged, arrested, or convicted of any crime in this state or under the laws of any state, or territory or possession of the United States.

Date ____________________                   X ________________________________________________
Signature of Applicant

TYPE OF IDENTIFICATION PRODUCED

Driver’s License Number: ______________________________ Expiration Date:_________  State:_________

Identification Card Number: ____________________________  Expiration Date:_________  State:_________

Sheriffs’ Employee: _________________________________    Personnel Number: ______________

(REV. 7-08) PAGE 2 OF 3

WAIVER AND AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

I authorize you to furnish the ___________________________________________  (Law Enforcement Agency) with any and all information that you have concerning me, my employment records, my reputation, my physical and mental condition and my military service records.  Information of a confidential or privileged nature may be included.  Your reply will be used to assist the police department in determining my qualifications and suitability for a Concealed Firearms Permit.

In compliance with Federal Confidentiality Rules (42 CFR, Part 2), this waiver includes the release of medical records pertaining to the voluntary and/or involuntary commitment to a mental health facility for treatment of physical and mental illness and alcohol/drug abuse.

In addition to the above requested information, you may release arrests, detentions,  field citations, field interview cards, officers’ records, jail/custody booking records, traffic citations, and traffic accident information, district attorney records, court records and reports, probation and parole reports and records, laboratory reports and results, and any other criminal justice records, reports or information source.

This authorization and request is given freely and without duress, voluntarily waiving any protection against unauthorized disclosure of information under the Privacy Act and any other legal provisions, and with the understanding that information furnished will be used by the _____________________________________________ (Law Enforcement Agency) in conjunction with my application for a Concealed Firearms Permit.

I hereby release you, your organization and others from any liability or damage which may result from furnishing the information requested, including any liability pursuant to any state or local code or ordinance or any similar laws.

THIS AUTHORIZATION IS VALID FOR FIVE (5) YEARS FROM THE DATE SIGNED.

I declare under penalty of perjury under the laws of the State of Nevada, that the foregoing is true and correct.

                                                                                                                      
Applicant’s Signature                                                         Date

                                                                            
Print Full Name

                                                                                                                      
SHERIFFS’ Employee                                                        Date

NOTE:   A PHOTOCOPY REPRODUCTION OF THIS REQUEST SHALL BE FOR ALL INTENTS AND PURPOSES AS VALID AS THE ORIGINAL.  YOU MAY RETAIN THIS FORM FOR YOUR FILES.

(Rev. 7- 08) PAGE 3 OF 3