Minnesota Uniform Firearm Application Permit to Carry a …

1 DATA PRACTICES ADVISORY Minnesota Uniform Firearm Application Permit TO Carry A PISTOL (TYPE OR PRINT ONLY) THIS Application MUST BE SUBMITTED IN PERSON CHECK TYPE NEW RENEWAL PERSONAL DATA CHANGE REPLACEMENT EMERGENCY NOTE: PERSONAL DATA CHANGE/ REPLACEMENT APPLICANTS NEED ONLY COMPLETE REQUIRED PERSONAL DATA AND SIGN WHERE INDICATED. NOTICE TO APPLICANT: An incomplete Application will be denied.

2 If an applicant is found to have knowingly falsified this Application or omitted pertinent information that person may be subject to criminal prosecution. The waiting period will begin on the date that t his Application is fully completed and submitted. The Minnesota Data Practices Act requires you be advised of the following: As an applicant for a Permit to Carry a pistol, you are being asked to provide private data about yourself that will be used to check various databases to determine your eligibility to possess a Firearm .

3 You may refuse to provide this data. If you refuse, the background check cannot be completed and your Application will not b e processed. Providing the data will Permit the background check to be completed. The result of the check may be either affirmative or negative. The data you provide may be shared with other criminal justice agencies, via court order or as authorized or required by law. I HAVE READ AND UNDERSTAND THE ABOVE DATA PRACTICES ADVISORY.

4 SIGNATURE: DATE: REQUIRED PERSONAL DATA NAME (LAST, FIRST, MIDDLE, JR/SR): BIRTH DATE: PHONE NO.: MAIDEN NAME (if applicable) OR OTHER NAMES YOU HAVE USED: PRESENT RESIDENCE ADDRESS: CITY/TOWNSHIP (if applicable): COUNTY: STATE: ZIP CODE: SEX: HEIGHT: WEIGHT: EYE COLOR: HAIR COLOR: STATE: DRIVER S LICENSE, STATE ID OR PASSPORT NUMBER: DISTINGUISHING PHYSICAL CHARACTERISTICS (INCLUDING SCARS, MARKS, TATTOOS, ETC.): PREVIOUS RESIDENCES (PAST 5 YEARS) FROM (Mo/Yr) TO (Mo/Yr) CITY TOWNSHIP (if applicable) COUNTY STATE Rev.

5 2015 1 DATA PRACTICES ADVISORY AUTHORIZATION FOR RELEASE OF HUMAN SERVICES DATA FOR BACKGROUND CHECKS NAME (LAST, FIRST, MIDDLE, JR/SR): BIRTH DATE: PHONE NO.: MAIDEN NAME (if applicable) OR OTHER NAMES YOU HAVE USED: PRESENT RESIDENCE ADDRESS: CITY/TOWNSHIP (if applicable): COUNTY: STATE: ZIP CODE: TO: Minnesota Department of Human Services or a similar government agency in another state that maintains data about civil commitments By signi ng this Authorization for Release of D ata I a m giving the Minnesota Department of Hum an Services or a simil ar government agency in another stat e permission to release th e following types of data about me to the named law enforcement agency.

6 I understand this data will be used by the law enforcement agency as part of a background check to determine whether I am eligible for a Permit to Carry , eligible to renew a Permit to Carry , or eligible for a Permit to purchase a Firearm . The data I am asking to be released would indicate whether I have been: Committed by a court as mentally ill, d evelopmentally disabled or mentally ill and dangerous to the public Committed by a court as chemically dependent Found incompetent to stand trial or found not guilty by reason of mental illness A peace officer informally admitted to a treatment facility for chemical dependencyThe data is to be released to the listed law enforcement agency: AGENCY NAME: AGENCY ADDRESS.

7 AGENCY CONTACT PERSON AND PHONE NUMBER: I u nderstand that by signing this form I a m requesting the data listed be sent to the law enforcement agency listed. I may cancel this consent at a ny time by writing to the Minnesota Department of H uman Services or government agency in another state. If d ata has already been released based on this consent, my request to cancel the release will not work for that data. I u nderstand when the data is sent to the law enforcement agency, the data could be redisclosed as allowed under federal and state law.

8 If I choose not t o sign this consent form, I m ay not b e able to receive a Permit . This consent will end five years from the date any Permit is issued unless I indicate an earlier date or event here: SIGNATURE: DATE: For Law Enforcement Use Only Permit Issue Date: Rev. 2015 2 RESTRICTIONS The following restrictions apply to the possession of firearms, to purchase/transfer permits, and reports of transfer for handguns and semiautomatic military-style assault weapons.

9 Individuals with restrictions shall not be entitled to possess a pistol or any other Firearm . The legal basis for the restrictions may be found in federal law (18 United States Code 922) or Minnesota law ( Minnesota Statutes, , , or ). Must be at least 21 years old to purchase a handgun or handgun ammunition from a federally licensed dealer. Must be at least 18 years old to purchase a semi-automatic assault rifle. Must not have been convicted, adjudicated delinquent or convicted as an extended jurisdiction juvenile of a crime of violence in Minnesota orelsewhere unless civil r ights have been restored and during that t ime you have not been convicted of any ot her c rime of.

10 This lifetime prohibition on possessing, receiving, shipping, or transporting firearms for persons convicted or adjudicateddelinquent of a crime of violence applies only to offenders who are discharged from sentence or court supervision for a crime ofviolence on or after August 1, 1993. Must not have been charged wit h a crime of violence or plac ed in a pretrial diversion program by the court before disposition until you havecompleted the diversion program and the charge of committing the crim e of violence has been dismissed.