STATE OF NORTH CAROLINA APPLICATION FOR …

1 Law Enforcement/Criminal Justice Use OnlyRevised07/15/201552of103 STATE OF NORTH CAROLINAAPPLICATION FORCONCEALED handgun PERMITNEW PERMITRENEWAL PERMITDUPLICATEEMERGENCY TEMPORARY PERMITName of Applicant (Last, First, Middle, Maiden)Attach listing of all previousaddresses and all name changes including location and court file number(If Applicable)Street AddressDate of BirthSocial Security Number(See Notification on page 3)CityStateZip Code( STATE ID NuStateMailing AddressMilitary StatusActiveReserveDischargedRetiredN/AR aceSexHairTelephone NumberCounty of ResidenceEyesHeightWeightOther Physical DescriptionAPPLICATIONI, the undersigned applicant,being duly sworn, hereby make APPLICATION for a NORTH CAROLINA concealed handgun Permitand STATE that the following information is correct to the best of my knowledge.)

2 (Check Appropriate Boxes) you a citizen of the United states ?(1) you 21 years of age or older?(2) you been a resident of NORTH CAROLINA for 30 days or longer immediately preceding the date of this APPLICATION ?(3) you suffer from a physical or mental infirmity that prevents the safe handling of a handgun ?(4) you successfully completed an approved firearms safety and training course which involved the actual firingof handguns and instruction in the laws of NORTH CAROLINA governing the carrying of a concealed handgun and theuse of deadly force?IfYes, attach documentation(5)YesNo**If No: Do you meet the retired law enforcementofficer exception in (A)?

3 *YesNoIf Yes, attach you ineligible to own, possess, or receive a firearm under the provisions of STATE or federal law?(6) you under indictment or has a finding of probable cause been entered against you for a pending felony charge?(7) you been adjudicated guilty in any court of a felony?(8)Yes*No*If Yes: Have your firearm rights been restored pursuant to *YesNoIf Yes, attach you a fugitive from justice?(9) you an unlawful user of (or addicted to) marijuana, alcohol, or any depressant, stimulant, or narcoticdrug,or any other controlled substance as defined in 21 802?(10) you currently or have you been previously adjudicated or administratively determined to be lackingmental capacity or mentally ill?

4 (11) you been discharged from the Armed Forcesunder conditions other than honorable?(12) you been adjudicated guilty of, or received a prayer for judgment continued for, or received a suspended sentencefor, one or more crimes of violence constituting a misdemeanor,including but not limited to, a violation of the disqualifyingcriminal offenses listed page 3 of this form?S(13) you had an entry of prayer for judgment continued for a criminal offense which would disqualify youfrom obtaining a handgun permit?(14) you free on bond or personal recognizancepending trial, appeal, or sentencing for a crime whichwould disqualify you from obtaining a concealed handgun permit?

5 (15)YesNoLaw Enforcement/Criminal Justice Use OnlyRevised07/15/201553of103I hereby apply for temporary emergency permit for a nonrenewable period of up to 45 days based upon theinformation set forth below. I reasonably believe thanan emergency situation exists whichmay constitute arisk of safety to me, my family, or my Grounds for Temporary Emergency Permit(Use attachment if necessary)SWORN TO AND SUBSCRIBED TO BEFORE MEDateDateSignature of Person Authorized to Administer OathsSignature of ApplicantTitleCAUTIONF ederal law and STATE law on the possession ofhandguns andfirearms may differ. If you are prohibited by federal law frompossessing a handgun or a firearm, you may be prosecuted infederal court.

6 A STATE permit is not a defense to a Commission ExpiresSEALSHERIFF USE ONLYC heck Listcheck applicable permit fee certificate of completionof approved firearms safety & training of APPLICATION Firearm Safety & Training (s) (specify): issued Temporary Permit: denied Temporary Permit: issued Permit: _____Permit Number: Permit: submitted to SBI: Transaction Number (NTN) of Sheriff:_____OriginalSheriff / CopySBI / CopyApplicantSBI CHPA, Rev 04/12 Page you been convicted of an impaired driving offense under , , or three years prior to the date of this APPLICATION ?(16)YesNoSBI CHPA, Rev 04/12 Page 1 Law Enforcement/Criminal Justice Use OnlyRevised07/15/201554of103 LIST OF DISQUALIFYING CRIMINAL of and communication of court poison, controlled substances, deadly weapons, cartridges, ammunition, or alcoholicbeverages to inmates of charitable, mental or penal institutions.

7 Or localconfinement weapons on campus or other educational weapons into assemblies and establishments where alcoholic beverages are soldand/or weapons on STATE property and and/or sale of spring-loaded projectile of a fireman or emergency medical services of a law enforcement officer or other public weapons at parades and other public or droppingobjects at sporting dynamite cartridges and/or and inciting a or conduct creating the threat of imminent fighting or other (a)(1) or using any utterance, gesture, display, or abusive language which is intendedand plainly likely to provoke violent retaliation, and thereby create a breach of (a)(2) and trespassing during an on emergency of city STATE of emergency of county STATE of emergency of STATE of emergency of the standards for carrying a concealed (b) on certification of qualified retired law enforcement (d) crime found in Chapter 14, Article 8 of the NORTH CAROLINA General SECURITY NUMBER:The disclosure of your social security number as a part of this concealed handgun permit APPLICATION isvoluntary.

8 The purpose of requesting the social security number is to assist in your identification and to help distinguishyou from otherpersons with similar names. No concealed handgun permit will be denied for failure to disclose a social security CHPA, Rev 04/12 Page 3 Law Enforcement/Criminal Justice Use OnlyRevised07/15/201555of103 concealed handgun ChartProhibited Carry AreasProhibitedCarryAreaIndividualsAutho rizedPursuant toGS 14-269(b)Out-of- STATE OfficerHR 218 ConcealedCarryHandgunPermitteeGS PropertyYESYESIf Secured inVehicleUnlessPrivateEducational Property inVehicleUnlessPrivateEducationalPropert y inVehicleUnlessPrivateEducationalPropert y AlcoholicBeverages are soldand consumedYESYESU nless PostedYESU nlessPostedYESU nlessPostedCertain StateProperty &Courthouses (Thisdoes not addressLegislative officeproperties.)

9 YESYESIf Secured inVehicleYESIfSecured inVehicleYESIfSecured inVehicleParades or FuneralProcessionsYESYESU nless PostedYESU nlessPostedYESU nlessPostedPicket lines, PrivateHealth Care FacilitiesYESNONONOP osted Propertysee note belowNONONOLaw Enforcement orCorrectional FacilityYESNONONOF ederal PropertyNONONONOW hile consumingalcohol or whilealcohol or controlledsubstance is in thebloodNONONONOA ssembly whereadmission is chargedYESYESU nless PostedYESU nlessPostedYESU nlessPostedState owned rest areaYESYESYESYESP osted localgovernmentrecreational facilitiesYESNONONOA "YES" in the block indicates the person in that category can carry in the establishment "NO" in the block indicates the person in that category cannot carry in the establishment.

10 While carrying in this area may not be in violation of our concealed carry statutes, it mayconstitute a trespass violation in certain 8/1/2013 Law Enforcement/Criminal Justice Use OnlyRevised07/15/201556of103 IndividualsAuthorized Pursuant to 14-269(b) enlisted personnel of the armed forces of the United states when in the discharge oftheir official duties as such and when acting under orders requiring them to carry arms and weapons; and law enforcement officers of the United states ; and soldiers of the Militia and the National Guard when called to actual service; of the STATE , or of any county, city, or town, charged with the execution of the laws of theState, when acting in the discharge of their official duties; person who is a district attorney, an assistant district attorney, or an investigator employed bythe office of a district attorney and who has a concealed handgun permit issued in accordance withArticle 54B of this Chapter or considered valid.