State of Ohio Application for a License License #: to ...

1 SECTION Application will not be processed unless all applicable questions have been answered and until allrequired supporting documents as described in division (B) or (F) of Section of the ohio RevisedCode have been provided and, unless waived, cash, cashier s check, or money order in the amount of theapplicable License fee or License renewal fee have been submitted. FEES ARE of OhioApplication for a Licenseto Carry a Concealed or Print in InkSECTION of Applicant: Last First MiddleCurrent PhysicalAddress: Street Address City State Zip CountyMailing Address(if different from above): Street Address City State Zip CountyTelephone #: Home Work CellDate of Birth.

2 Social Security #: E-mail Address: Issuing Agency Use OnlyLicense #: Date Issued: Type: Original RenewalFee Collected: Receipt#: SECTION III. THE FOLLOWING QUESTIONS ARE TO BE ANSWERED YES OR NO.(1) Have you lived in ohio five years or more?.. YES NO(2) Have you been a resident of ohio for at least 45 days and a resident of the countyof Application (or adjacent county) for at least 30 days? .. YES NO(3) Are you at least 21 years of age? .. YES NO(4) Have you ever applied for a concealed carry handgun License in another county in ohio ? .. YES NO If yes, what county? Date: (5) Have you ever been denied a concealed carry handgun License in another county in ohio ? .. YES NO If yes, what county? Date: (6) Are you a fugitive from justice?

3 YES NO(7) Are you prohibited by federal law from possessing a firearm?.. YES NO(8) Are you under indictment for a felony, have you ever been convicted of or pleaded guilty to a felony,or have you ever been adjudicated a delinquent child for committing an act that would be a felonyif committed by an adult?.. YES NO(9) Are you under indictment, or otherwise charged with, or have you ever been convicted of or pleaded guilty toan offense under Chapter 2925, 3719, or 4729 of the ohio Revised Code, or a similar offense in any other State ,that involves illegal possession, use, sale, administration, distribution of or trafficking in a drug of abuse,or have you ever been adjudicated a delinquent child for committing an act that would be an offense of thatnature if committed by an adult?

4 YES NO(10) Have you ever been convicted of, or pleaded guilty to, a charge of domestic violence, or a similar offense,in this or any other State ? .. YES NO(11) Are you under indictment for, or otherwise charged with, or have you been convicted of or pleaded guilty to,within three years of the date of this Application , a misdemeanor that is an offense of violence or theoffense of possessing a revoked or suspended concealed handgun License , or have you been adjudicateda delinquent child within three years of the date of this Application , for committing an act that would bea misdemeanor of that nature, if committed by an adult?.. YES NOPage 1 of 4 Sex of Applicant: Male FemaleRace/National Origin of Applicant: White Hispanic American Indian/Alaskan Native Black Asian/Pacific Islander Other ApplicantPhoto(12) Are you under indictment for or otherwise charged with, or have you been convicted of or pleaded guilty to,within 10 years of the date of this Application , resisting arrest, or have you been adjudicated a delinquent childfor committing, within 10 years of the date of this Application , an act that if committed by an adultwould be the offense of resisting arrest?

5 YES NO(13) (a) Are you under indictment for, or otherwise charged with, assault or negligent assault? .. YES NO(b) Have you been convicted of, pleaded guilty to, or adjudicated a delinquent child two or more times forcommitting assault or negligent assault within five years of the date of this Application ? .. YES NO(c) Have you ever been convicted of, pleaded guilty to, or adjudicated a delinquent childfor assaulting a peace officer?.. YES NO(14) (a) Have you ever been adjudicated as mentally incompetent? .. YES NO(b) Have you ever been committed to a mental institution?.. YES NO(c) Have you ever been voluntarily committed to a mental hospital or facilityfor purposes other than observation? .. YES NO(d) Have you ever been adjudicated mentally defective (which includes having been adjudicated incompetentto manage your own affairs), or ever been committed to a mental institution?

6 YES NO(15) Are you drug dependent, in danger of being drug dependent, or a chronic alcoholic? .. YES NO(16) Are you currently the subject of a civil protection order, a temporary protection order, or a protection orderissued by a court of this or any other State ?.. YES NOSECTION must complete this section of the Application by providing, to the best of your knowledge, the address of each place ofresidence at which you resided at any time since you attained age 18 and until you commenced your residence at the locationidentified in Section II of this form. If you need more room for the information below, continue in the space provided on page 4of this Application . LIST PREVIOUS RESIDENCES CHRONOLOGICALLY, BEGINNING WITH THE MOST 1: Street Address City State Zip County Dates of residence at this address:From to.

7 From to .Residence 2: Street Address City State Zip County Dates of residence at this address:From to . From to .Residence 3: Street Address City State Zip County Dates of residence at this address:From to . From to .SECTION V. TO BE COMPLETED BY THE ISSUING AUTHORITY of Competency: Original Renewal Prior EquivalentIf Original or Renewal, date Certificate issued: Entity Name: Instructor Name: ID #: (OPOTC or NRA ID #)If Prior Equivalent, what type: Law EnforcementRetirement date: What documents have been provided to evidence Prior Equivalent Training Experience: Military Active/Reserve provide Active Duty credentials Retired/Honorable Discharge date: What documents have been provided to evidence Prior Equivalent Training Experience: Does Competency Certification provided meet the requirements specified in (B)(3)(a)-(f)?

8 Yes NoPage 2 of 4 SECTION APPLICANT WHO KNOWINGLY PROVIDES A FALSE ANSWER TO ANY QUESTION, OR SUBMITS FALSEINFORMATION OR A FALSE DOCUMENT WITH THIS Application , MAY BE PROSECUTED FORFALSIFICATION TO OBTAIN A CONCEALED HANDGUN License , IN VIOLATION OF ohio REVISED CODESECTION , A FELONY OF THE FOURTH UNDERSIGNED MUST ATTEST TO THE FOLLOWING:(1) I have been furnished, and have read, the publication that explains the ohio firearms laws, that provides instruction indispute resolution, and explains the ohio laws related to that matter, and that provides information regarding all aspects ofthe use of deadly force with a firearm, and I am knowledgeable of the provisions of those laws and of the information onthose matters.(2) I desire a legal means to carry a concealed handgun for defense of myself, or a member of my family, while engagedin lawful activity and will carry the concealed handgun in a lawful manner.

9 (3) I have never been convicted of or pleaded guilty to a crime of violence in the State of ohio , or elsewhere. I am ofsound mind, and I hereby certify that the statements contained herein are true and correct to the best of my knowledge andbelief. I understand that if I knowingly make any false statements herein I am subject to penalties prescribed by law. Iauthorize the sheriff, or the sheriff s designee, to inspect only those records or documents relevant to information requiredfor this Application .(4) The information contained in this Application and all attached documents are true and correct to the best of myknowledge. Signature of Applicant DateTO BE COMPLETED BY THE ISSUING AUTHORITY ONLYA pplication received: By: Application review is to be completed by: Application reviewed by: Foreign notification sent: Foreign notification response received: Background completed: Background records destroyed: By: Approved date: Process suspended date: Reason: Denied date: Reason: LEADS entry date: Entry #: By: Page 3 of 4 Date Name of Intake Person Date Name of ReviewerDate DateDate Date NameNameContinuation of residency information from SECTION IV on page 4.

10 Street Address City State Zip County Dates of residence at this address:From to . From to .Residence 5: Street Address City State Zip County Dates of residence at this address:From to . From to .Residence 6: Street Address City State Zip County Dates of residence at this address:From to.