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UPDATED 05/2021 STATE OF MONTANA, COUNTY OF BIG HORN Concealed Weapons Permit Application Incomplete Applications Will Not Be Processed. PAYMENT ACCEPTED UPON THE APPROVAL OF THE PERMIT To Be Completed by Applicant NEW RENEWAL Exp. Date: Resident of Montana for at least 6 months? YES NO Citizen of the United States? YES NO 18 years of age or older? YES NO Big Horn County Resident? YES NO PLEASE PRINT OR TYPE Full Name: Last First Middle Alias/Maiden/Nickname: _ Physical Address: Street/Apt # City State Zip Mailing Address: Street/Apt # or PO Box City State Zip Phone: / / Home Message/Cell Work Email Address: Employer Name: Employer Address: Street City State Zip Place of Birth: Date of Birth: Driver’s License Issuing State: Expires: *Social Security Race: *Will NOT appear on your permit, however it is required for your background check* Sex: Hgt.: FT IN Wt.: Hair: Eyes: ---PAGE BREAK--- UPDATED 05/2021 Do you have firearms training? YES NO Do you have Hunter’s Education training? YES NO If you do not have a certificate of completed training in either course you will be required to complete a firearms knowledge checklist and hands-on Range Day with the Firearms Instructor to show them you have the proper knowledge to use a firearm. MILITARY SERVICE YES NO Branch: From: to Type of Discharge: Rank Upon Discharge: LIST ALL EMPLOYERS OR BUSINESS ACTIVITY FOR THE PAST FIVE YEARS: Employer or Business Name Address Dates of Employment ▪ ▪ ▪ ▪ ▪ ▪ LIST EACH PLACE IN WHICH YOU HAVE LIVED FOR THE PAST FIVE YEARS: City State Dates of Residence ▪ ▪ ▪ ▪ ▪ ▪ THE FOLLOWING QUESTIONS ARE VERY SPECIFIC. IF YOU HAVE EVER BEEN ARRESTED FOR ANY REASON, YOU MUST MARK “YES”. THIS INCLUDES ANY INCIDENT. EVEN IF YOU WERE NOT CHARGED, THE CHARGES WERE DISMISSED OR BELIEVE THAT THE CHARGES WERE REMOVED FROM YOUR RECORD. LESS THAN TRUTHFUL RESPONSES WILL RESULT IN THE DENIAL OF THIS APPLICATION. AGAIN, THIS INCLUDES ANY ARREST OR CHARGE OR CONVICTION EVER. ---PAGE BREAK--- UPDATED 05/2021 1. Are you under indictment or information in any court for a felony, or any other crime for which the judge could imprison you for more than one year, or are you a current member of the military who has been charged with violation(s) Of the Uniform Code of Military Justice and whose charge(s) have been referred to a general court-martial? YES NO 2. Have you ever been convicted in any court, including a military court, of a felony, or any other crime for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence including probation? YES NO 3. Are you a fugitive from justice? YES NO 4. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance? Warning: The use or possession of marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in the state where you reside. YES NO 5. Have you ever been adjudicated as a mental defective OR have you ever been committed to a mental institution? YES NO 6. Have you ever been discharged from the Armed Forces under dishonorable conditions? YES NO 7. Are you subject a court order, including Military Protection Order issued by a military judge or magistrate, restraining you from harassing, stalking, or threatening your child or an intimate partner or child of such partner? YES NO 8. Have you ever been convicted in any court of a misdemeanor crime of domestic violence, or are you or have you ever been a member of the military and been convicted of a crime that included, as an element, the use of force against a person? YES NO 9. Have you ever renounced your United States citizenship? YES NO 10. Are you an alien illegally or unlawfully in the United States? YES NO If you answered YES, complete the following (Attach additional sheet if necessary): City State Charge Disposition Date ▪ ▪ ▪ ▪ ▪ ---PAGE BREAK--- UPDATED 05/2021 LIST THREE PERSONS WHOM YOU HAVE KNOWN FOR AT LEAST FIVE YEARS THAT WILL BE CREDIBLE WITNESSES TO YOUR GOOD MORAL CHARACTER AND PEACEABLE DISPOSITION. (DO NOT LIST RELATIVES OR PRESENT/PAST EMPLOYERS) Name Address – Street/City/State Telephone Number 1. 2. 3. PLEASE EXPLAIN YOUR REASONS FOR REQUESTING THIS PERMIT (ATTACH ADDITIONAL SHEET IF NECESSARY): I, the undersigned applicant, swear that the foregoing information is true and correct to the best of my knowledge and belief and is given with the full knowledge that any misstatement contained herein may be sufficient cause for denial or revocation of a permit to carry a concealed weapon. I hereby authorize any person having information concerning me that relates to the information requested by this application and the requirements for a concealed weapon permit, either public record or otherwise to furnish it to the sheriff to whom this application is made. If any circumstances arise that requires the Sheriff to revoke the permit, I will surrender the concealed weapons permit to any Peace Officer after written notification by the Sheriff. I have read and understand all the above: *This application MUST be signed in the presence of the Sheriff or designee. Signature Date Signature witnessed by: (initials) FOR OFFICIAL USE ONLY: Received By: Date: Photo: Y Fingerprints: Y N Background Check: Date: Completed: Date: Permit NTN: DOJ Exp. Date: ---PAGE BREAK--- UPDATED 05/2021 BIG HORN COUNTY SHERIFF’S OFFICE CONCEALED WEAPONS PERMIT PERSONAL REFERENCE QUESTIONNAIRE DATE: NAME OF CCW APPLICANT: REFERENCE INFORMATION: (NAME) (ADDRESS) (DAYTIME PHONE NUMBER) 1. HOW LONG HAVE YOU KNOWN THE APPLICANT? 2. ARE YOU A RELATIVE OR PRESENT/PAST EMPLOYER OF THE APPLICANT? 3. ARE YOU WILLING TO BE A WITNESS TO THE APPLICANT’S GOOD MORAL CHARACTER AND PEACEABLE DISPOSITION? NO SIGNATURE OF PERSON COMPLETING THIS QUESTIONNAIRE ---PAGE BREAK--- UPDATED 05/2021 BIG HORN COUNTY SHERIFF’S OFFICE CONCEALED WEAPONS PERMIT PERSONAL REFERENCE QUESTIONNAIRE DATE: NAME OF CCW APPLICANT: REFERENCE INFORMATION: (NAME) (ADDRESS) (DAYTIME PHONE NUMBER) 4. HOW LONG HAVE YOU KNOWN THE APPLICANT? 5. ARE YOU A RELATIVE OR PRESENT/PAST EMPLOYER OF THE APPLICANT? 6. ARE YOU WILLING TO BE A WITNESS TO THE APPLICANT’S GOOD MORAL CHARACTER AND PEACEABLE DISPOSITION? NO SIGNATURE OF PERSON COMPLETING THIS QUESTIONNAIRE ---PAGE BREAK--- UPDATED 05/2021 BIG HORN COUNTY SHERIFF’S OFFICE CONCEALED WEAPONS PERMIT PERSONAL REFERENCE QUESTIONNAIRE DATE: NAME OF CCW APPLICANT: REFERENCE INFORMATION: (NAME) (ADDRESS) (DAYTIME PHONE NUMBER) 7. HOW LONG HAVE YOU KNOWN THE APPLICANT? 8. ARE YOU A RELATIVE OR PRESENT/PAST EMPLOYER OF THE APPLICANT? 9. ARE YOU WILLING TO BE A WITNESS TO THE APPLICANT’S GOOD MORAL CHARACTER AND PEACEABLE DISPOSITION? NO SIGNATURE OF PERSON COMPLETING THIS QUESTIONNAIRE