Form DPS-67-C "Application to Purchase a Firearm" - Connecticut

What Is Form DPS-67-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 11, 2016;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DPS-67-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DPS-67-C "Application to Purchase a Firearm" - Connecticut

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APPLICATION TO PURCHASE A FIREARM –
Pursuant to C.G.S. §§ 29-33 and 29-37a
:
WEAPON TYPE
HANDGUN
LONG GUN
OTHER
SALE AUTHORIZATION NUMBER(S)
Name:
Date of Birth:
(Last, First, Middle)
(MM/DD/YYYY)
Address:
Include number, street, town, state and zip (Post Office boxes not accepted)
Sex:
Race:
Height:
Weight:
Eye Color:
Hair Color:
Social Security Number:
Country of Citizenship:
ICE Number:
(optional, but will help
(required)
(if applicable)
prevent misidentification)
Pistol Permit Number/Eligibility Certificate Number:
Expiration Date:
(required)
Police Identification Number:
Agency Name:
Motor Vehicle Operator’s License Number:
State:
Expiration Date:
(required)
(MM/DD/YYYY)
a. Have you been convicted of a felony?
Yes
No
b. Have you ever been convicted of a misdemeanor crime of domestic/family violence?
Yes
No
c. Are you the subject of an active restraining or protective order issued by a court, after notice and an opportunity to
be heard has been provided to you, in a case involving the use, attempted use or threatened use of physical force
against another person?
Yes
No
d. Have you ever been confined to a hospital for persons with psychiatric disability (C.G.S. § 17a-495) within the preceding sixty (60) months
by order of a Probate Court?
Yes
No
e. Have you been voluntarily admitted to a hospital for persons with psychiatric disabilities, within the preceding six (6) months for
reasons other than solely for alcohol or drug dependence?
Yes
No
f. Have you been discharged from custody within the preceding twenty (20) years after having been found not
guilty of a crime by reason of mental disease or defect pursuant to Connecticut General Statutes Section 53a-13?
Yes
No
g. Are you the subject of a court issued risk warrant to seize firearms pursuant to C.G.S. § 29-38c(d)?
Yes
No
h. Have you ever had an application to purchase a firearm denied in any other State?
Yes
No
If so, Where
When?
Reason for denial?
i. Have you ever been convicted of any of the following misdemeanors?
Yes
No
If yes, check all that apply.
Illegal possession of controlled or hallucinogenic substances (C.G.S. § 21a-279)
rd
Assault of an elderly, blind, disabled or pregnant person or a person with intellectual disability in the 3
(C.G.S. § 53a-61a)
nd
Criminally negligent homicide (C.G.S. § 53a-58)
Unlawful restraint 2
(C.G.S. § 53a-96)
rd
st
Assault in the 3
(C.G.S. § 53a-61)
Riot 1
(C.G.S. § 53a-175)
nd
nd
Threatening 2
(C.G.S. § 53a-62
Riot 2
(C.G.S. § 53a-176)
st
Reckless endangerment 1
(C.G.S. § 53a-63)
Inciting to riot (C.G.S. § 53a-178)
nd
Stalking 2
(C.G.S. § 53a-181d)
Information provided on this application is subject to verification from sources including probate, civil, and criminal courts as well as governmental agencies
pursuant to State and Federal Law.
I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS DOCUMENT
IS A VIOLATION OF CONNECTICUT GENERAL STATUTES SECTIONS 29-34 AND/OR 29-37e AND CONSTITUTES A FELONY.
SIGNATURE OF PURCHASER
DATE
I UNDERSTAND THAT A PERSON WHO ANSWERS, “YES” TO QUESTIONS A-G IS PROHIBITED FROM PURCHASING A FIREARM. THOSE
APPLICANT’S ANSWERING IN THE AFFIRMATIVE TO QUESTIONS H AND I, MAY BE PROHIBITED UPON COMPLETION OF A BACKGROUND
CHECK.
SIGNATURE OF SALESPERSON
DEALER NAME, IF APPLICABLE
DATE
THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY THE SELLER AND PURCHASER
DPS-67-C (Rev. 03/11/16-
Previous editions are obsolete
) An Affirmative Action/Equal Employment Opportunity Employer
APPLICATION TO PURCHASE A FIREARM –
Pursuant to C.G.S. §§ 29-33 and 29-37a
:
WEAPON TYPE
HANDGUN
LONG GUN
OTHER
SALE AUTHORIZATION NUMBER(S)
Name:
Date of Birth:
(Last, First, Middle)
(MM/DD/YYYY)
Address:
Include number, street, town, state and zip (Post Office boxes not accepted)
Sex:
Race:
Height:
Weight:
Eye Color:
Hair Color:
Social Security Number:
Country of Citizenship:
ICE Number:
(optional, but will help
(required)
(if applicable)
prevent misidentification)
Pistol Permit Number/Eligibility Certificate Number:
Expiration Date:
(required)
Police Identification Number:
Agency Name:
Motor Vehicle Operator’s License Number:
State:
Expiration Date:
(required)
(MM/DD/YYYY)
a. Have you been convicted of a felony?
Yes
No
b. Have you ever been convicted of a misdemeanor crime of domestic/family violence?
Yes
No
c. Are you the subject of an active restraining or protective order issued by a court, after notice and an opportunity to
be heard has been provided to you, in a case involving the use, attempted use or threatened use of physical force
against another person?
Yes
No
d. Have you ever been confined to a hospital for persons with psychiatric disability (C.G.S. § 17a-495) within the preceding sixty (60) months
by order of a Probate Court?
Yes
No
e. Have you been voluntarily admitted to a hospital for persons with psychiatric disabilities, within the preceding six (6) months for
reasons other than solely for alcohol or drug dependence?
Yes
No
f. Have you been discharged from custody within the preceding twenty (20) years after having been found not
guilty of a crime by reason of mental disease or defect pursuant to Connecticut General Statutes Section 53a-13?
Yes
No
g. Are you the subject of a court issued risk warrant to seize firearms pursuant to C.G.S. § 29-38c(d)?
Yes
No
h. Have you ever had an application to purchase a firearm denied in any other State?
Yes
No
If so, Where
When?
Reason for denial?
i. Have you ever been convicted of any of the following misdemeanors?
Yes
No
If yes, check all that apply.
Illegal possession of controlled or hallucinogenic substances (C.G.S. § 21a-279)
rd
Assault of an elderly, blind, disabled or pregnant person or a person with intellectual disability in the 3
(C.G.S. § 53a-61a)
nd
Criminally negligent homicide (C.G.S. § 53a-58)
Unlawful restraint 2
(C.G.S. § 53a-96)
rd
st
Assault in the 3
(C.G.S. § 53a-61)
Riot 1
(C.G.S. § 53a-175)
nd
nd
Threatening 2
(C.G.S. § 53a-62
Riot 2
(C.G.S. § 53a-176)
st
Reckless endangerment 1
(C.G.S. § 53a-63)
Inciting to riot (C.G.S. § 53a-178)
nd
Stalking 2
(C.G.S. § 53a-181d)
Information provided on this application is subject to verification from sources including probate, civil, and criminal courts as well as governmental agencies
pursuant to State and Federal Law.
I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING FALSE INFORMATION ON THIS DOCUMENT
IS A VIOLATION OF CONNECTICUT GENERAL STATUTES SECTIONS 29-34 AND/OR 29-37e AND CONSTITUTES A FELONY.
SIGNATURE OF PURCHASER
DATE
I UNDERSTAND THAT A PERSON WHO ANSWERS, “YES” TO QUESTIONS A-G IS PROHIBITED FROM PURCHASING A FIREARM. THOSE
APPLICANT’S ANSWERING IN THE AFFIRMATIVE TO QUESTIONS H AND I, MAY BE PROHIBITED UPON COMPLETION OF A BACKGROUND
CHECK.
SIGNATURE OF SALESPERSON
DEALER NAME, IF APPLICABLE
DATE
THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY THE SELLER AND PURCHASER
DPS-67-C (Rev. 03/11/16-
Previous editions are obsolete
) An Affirmative Action/Equal Employment Opportunity Employer