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DPS 445 (5/16) APPLICATION FOR WEAPONS CARRY LICENSE Applicant’s First Middle Last (or as registered with INS) Maiden Name, Aliases & Names Previously Date of Birth: (Age if + attach proof of completed basic training or honorable discharge) INS Alien/Admission No. Sex: Race: Height: Weight: Hair Eye Color: Place of Birth: City State, Province or District Country Residence/Street Address: City, State, Zip: County: Mailing Address if different: Phone Numbers: Home Other GA Military Base of non-resident who is active military (attach copy of active duty orders) 1. Are you currently a United States Citizen? Yes No Have you ever renounced your U.S. citizenship? Yes No If so, attach a copy of the reversal of renunciation. ►If you are not a U.S. Citizen: • You must show proof of name/address/date of birth/place of birth/INS or ICE number/photo ID. • Identify all countries of citizenship: • Attach: documentation of your lawful presence in the United States, for example: As to Immigrant Aliens: Resident Alien card, Permanent Resident Card or Immigrant Visa with Adit Stamp; OR As to Non-Immigrant Aliens: a Student Visa, Tourist Visa, Employment Authorization Card, or valid Passport with Arrival/Departure Record; and proof of residency in the State of Georgia. 2. Are you a non-immigrant (temporarily admitted) alien? [See Yes No If yes, attach proof that you fall within an exemption establishing your eligibility. Liberty County, Georgia County Number 089 ALL QUESTIONS MUST BE ANSWERED OR APPLICATION WILL BE DELAYED RESET FORM ---PAGE BREAK--- DPS 445 (5/16) 3. Have you been convicted of or pled guilty to any offense or court-martial charge involving the unlawful possession or use of a controlled substance or dangerous drug within the past five years or served any portion of incarceration or probation for use or possession of a controlled substance within the past five Yes No If yes and the foregoing conviction was for a misdemeanor drug offense, have you also within the past five years been convicted of, or served any portion of incarceration or probation in that time for a second misdemeanor drug offense involving use or possession of a controlled substance, unlawful manufacture or distribution of a controlled substance or dangerous drug, or of unlawful possession or shipping of a firearm, or had a weapons carry license revoked within the last 3 Yes No If pardoned and firearms rights restored, attach copy of pardon. 4. Have you ever been convicted of, or pled guilty to, any misdemeanor crime involving the use or attempted use of physical force or threatened use of a deadly weapon towards anyone as to whom at the time of the offense you were a current or former spouse, parent or guardian or similarly situated to a spouse, parent or guardian, a person with whom you had a child in common, or a person you lived with or had lived with as a spouse, parent or guardian or similarly situated to a spouse, parent or guardian, including but not limited to a girlfriend, boyfriend, step-child, foster child or Yes No If pardoned and firearms rights restored, attach copy of pardon. 5. Have you ever been convicted of or pled guilty to any felony offense or any offense punishable by a term of imprisonment over one year, including a conviction by a court-martial under the Uniform Code of Military Justice for an offense which would constitute a Yes No If pardoned and firearms rights restored, attach copy of pardon. 6. Have you ever been convicted of or pled guilty to any offense arising out of the unlawful manufacture or distribution of a controlled substance or dangerous Yes No If pardoned and firearms rights restored, attach copy of pardon. 7. Have you ever been convicted of or pled guilty to carrying a weapon without a weapons carry license, or carrying a weapon or long gun in an unauthorized Yes No If so, have you served any portion of incarceration or probation for such firearms offense in the past five years or had any other conviction or guilty plea within the past five Yes No Attach proof of the date your term of incarceration or probation ended, whichever is later (if any). 8. Are you under current indictment or information (formal charges) for a crime punishable by imprisonment for a term exceeding one year? Yes No 9. Have you left any state or any foreign jurisdiction to avoid criminal prosecution, to avoid testifying in any criminal proceeding, or knowing that charges are pending against No 10. Have you tested positive for drugs in the past year, admitted to having used drugs within the past year, or been arrested more than once in the last five years with the last arrest having been in the past year for any offense arising out of the unlawful possession, manufacturing, distribution or use of a controlled substance or other dangerous Yes No ---PAGE BREAK--- DPS 445 (5/16) 11. Do you use any controlled substance or illegal drug other than as prescribed by a licensed physician, or have you done so within the past year, or regularly used any such drug within the past five years? Yes No 12. Are you addicted to or have you lost self-control over any controlled substance or drug? Yes No 13. Are you, or have you ever been, subject to any court order (including but not limited to restraining orders, protective orders, peace bonds & good behavior bonds) restraining you from harassing, stalking, threatening, engaging in communication with, or refraining in any manner from contact with or coming in proximity to any current or former spouse, any person with whom you have a child in common, or person with whom you live or lived while in a sexual relationship?.……………….…… Yes No If yes, attach a copy of the order and any later order terminating or superceding the original order. 14. Have you ever been dishonorably discharged from the U.S. Armed Forces, or separated from the U.S. Armed Forces under a dismissal adjudged by a general court-martial? Yes No 15. Have you ever been found by a civil or criminal court, board, commission or other lawful authority, as a result of subnormal intelligence, incompetency, mental illness, condition or disease, to be a danger to yourself or others, to lack the mental capacity to manage your own affairs, or to be incompetent to stand trial, guilty but mentally ill, or not guilty by reason of insanity or not guilty for lack of mental responsibility? Yes No 16. Have you ever been hospitalized as an inpatient in any mental hospital or alcohol or drug treatment center within the past 5 years, or have you ever been ordered to receive inpatient or outpatient treatment at any treatment facility, mental health center, hospital, sanitarium, clinic or program for a mental condition, drug abuse, or alcohol abuse, by any court, board, or other authority in any civil, criminal or administrative proceeding? (If yes, attach a copy of the Yes No 17. Have you had a weapons carry license revoked by a judge of a probate court within the past 3 years? Yes No **DO NOT SIGN UNTIL APPOINTMENT WITH PROBATE COURT** I do swear and affirm under penalty of false swearing or perjury that the foregoing information is true and correct to the best of my knowledge and belief. APPLICANT’S SIGNATURE Sworn to and subscribed before me This day of FOR COURT USE ONLY: On the applicant was: Clerk of Probate Court issued a firearms license _____denied a firearms license Judge/Clerk, Probate Court SUBMIT FORM