USF 2020

APPLICATION TO PURCHASE A FIREARM

WEAPON TYPE:

HANDGUN

LONG GUN

OTHER

SALE AUTHORIZATION NUMBER:

____________________________________
NAME (LAST, FIRST, MIDDLE):
______________________________________________
DATE OF BIRTH: (//)
ADDRESS: ____________________________________________________________
SEX: MALE
RACE: WHITE

(PO BOXES NOT ACCEPTED)

FEMALE

AFRICAN AMERICAN
AMERICANINDIAN/NATIVEALASKAN
HISPANIC
ASIAN
OTHER: _______________________________________

HEIGHT: ______________________________________
WEIGHT: ______________________________________
EYE COLOR: ___________________________________
SOCIAL SECURITY NUMBER: ____________________
DRIVERS LICENSE NUMBER: ____________________
STATE: __________________________________
EXPIRATION DATE: _______________________
COUNTRY OF CITIZENSHIP: _____________________
ICE NUMBER: __________________________________
PISTOL PERMIT NUMBER: _______________________
ELIGIBILITY CERTIFICATE NUMBER: ______________
EXPIRATION DATE: _______________________
POLICE IDENTIFICATION NUMBER: ______________
AGENCY NAME: _______________________________

HAVE YOU EVER COMMITTED A FELONY?

YES

NO

USF 2020
IF YES, PLEASE SPECIFY:
_______________________________________________________________

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
IF YES, PLEASE SPECIFY:
_______________________________________________________________

HAVE YOU EVER BEEN CONFINED TO A HOSPITAL FOR PERSONS

WITH PSYCHIATRIC DISABILITY BY ANY ORDER? YES
NO
IF YES, PLEASE SPECIFY:
_______________________________________________________________

HAVE YOU BEEN VOLUNTARILY ADMITTED TO A HOSPITAL FOR

PERSONS WITH PSYCHIATRIC DISABILITIES?
YES
NO
IF YES, PLEASE SPECIFY:
_______________________________________________________________

HAVE YOU EVER BEEN DISCHARDED FROM CUSTODY AFTER

BEING FOUND NOT GUILTY OF A CRIME BY REASON OF MENTAL
DISEASE? YES
NO
IF YES, PLEASE SPECIFY:
_______________________________________________________________

ARE YOU THE SUBJECT OF A COURT ISSUED RISK WARRANT TO

SEIZE FIREARMS? YES
NO
IF YES, PLEASE SPECIFY:
_______________________________________________________________

HAVE YOU EVER HAD AN APPLICATION TO PURCHASE A

FIREARM DENIED IN ANY OTHER STATE? YES
NO
IF YES, PLEASE SPECIFY:
_______________________________________________________________

USF 2020
HAVE YOU EVER BEEN CONVICTED OF ANY OF THE FOLLOWING
MISDEMEANORS?
IF YES, CHECK ALL THAT APPLY
ILLEGAL POSSESSION OF CONTROLLED OR HALLUCINOGENIC SUBSTANCES
CRIMINALLY NEGLIGENT HOMICIDE
ASSULT OR BATTERY
ASSAULT OF A VICTIM 60 OR OLDER
UNLAWFUL RESTRAINT
ASSAULT IN THE 3RD
RECKLESS ENDANGERMENT
RIOT 1ST
RIOT 2ND
INCITING TO RIOT
STALKING

PLEASE REFER TO THE ATF FORM 4473 SECTION A FOR REGARDING

ANY QUESTIONS.

USF 2020
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 CLASS D FELONY OR IN SOME CASES, A CLASS B FELONY.
X______________________________________________________________________

SIGNATURE OF PURCHASER DATE

X______________________________________________________________________

I UNDERSTAND THAT A PERSON WHO ANSWERS, YES TO

QUESTIONS A-G IS PROHIBITED FROM PURCHASING A FIREARM.
THOSE APPLICANTS ANSWERING IN THE AFFIRMATIVE TO
QUESTIONS H AND I, MAY BE PROHIBITED UPON COMPLETION
OF A BACKGROUND CHECK.
X______________________________________________________________________

SIGNATURE OF SALESPERSON DEALER NAME, IF APPLICABLE

DATE
X______________________________________________________________________

THIS FORM MUST BE FILLED OUT COMPLETELY AND LEGIBLY BY

THE SELLER AND PURCHASER