Pawtucket Police Department

Pawtucket Police Department

121 Roosevelt Avenue

Pawtucket, RI 02860

401-727-9100

Mayor Donald GrebienChief Tina Goncalves

APPLICATION FOR LICENSE TO CARRY A CONCEALABLE WEAPON

DATE:______PERMIT NUMBER:______

FOR OFFICE USE ONLY

NAME: ______

FIRSTMIDDLELAST

Any Former Name(s) or Alias: ______

______

Please List any Nicknames: ______

Date of Birth: ______Place of Birth: ______

Social Security Number: ______Driver License: ______

State and Number

Height:______Weight: ______Eye Color: ______Hair Color: ______

Are you a citizen of the United States? ______How Long? ______

(NOTE: IF YOU ARE NOT A CITIZEN OF THE UNITED STATES, A COPY OF BOTH SIDES OF YOUR ALIEN REGISTRATION CARD MUST BE INCLUDED WITH THIS APPLICATION)

“Committed to Excellence”

Pawtucket Police Department

BELOW PLEASE LIST YOUR CURRENT PERMANENT RESIDENCE ADDRESS AND ANY OTHER ADDRESSES YOU HAVE USED IN THE PAST 3 YEARS. USE A SEPARATE PAPER IF NECESSARY.

______

Street Name and NumberCity or TownState and ZipDates From/To

______

Street Name and NumberCity or TownState and ZipDates From/To

______

Street Name and NumberCity or TownState and ZipDates From/To

Telephone Numbers: ______

HomeBusinessOther

Current Employer: ______

NameFull AddressTelephone Number

Occupation: ______Length of Employment: ______

Detailed Job Description: ______

______

Have you ever been arrested? ______If so, please provide details: ______

______

Have you ever been under guardianship, confined, or treated for mental illness? ______

If so, please provide details: ______

______

Pawtucket Police Department

Have you ever been convicted of a crime?______If so, please provide details: ______

______

Have you ever plead Nolo-Contendre to any charge or violation? ______

If so, please provide details: ______

Are you under Indictment in any court for a crime punishable by imprisonment exceeding one year? ______

If so, please provide details: ______

Have you ever applied for a permit to carry a concealed pistol or revolver from the Attorney General’s Office,

or a local city or town in Rhode Island? ______If yes what agency/municipality?______

______

If yes, is/was it: ACTIVE: ______EXPIRED: ______DENIED: ______REVOKED: ______

(IF YOU HOLD AND EXPIRED PERMIT, ENCLOSE A PHOTOCOPY, SIGNED AND DATED BY A NOTARY ATTESTING COPIES ARE TRUE)

Have you ever applied for a permit to carry concealed in another state? ______

If yes, provide city and state: ______

Were you denied, or was the permit revoked? ______If yes, please provide details: ______

______

(PLEASE ENCLOSE A PHOTOCOPY OF ANY OUT OF STATE PERMIT OR LICENSE)

Pawtucket Police Department

TO THE CHIEF OF POLICE OR CITY HALL OFFICIAL OF ______

City or Town and State

THIS IS TO INFORM YOU THAT ______

Applicant’s Name(typed or printed)

IS APPLYING FOR A PERMIT TO CARRY A CONCEALED PISTOL OR REVOLVER IN THE STATE OF RHODE ISLAND. WE WOULD REQUEST THAT YOU VERIFY THAT THIS INDIVIDUAL RESIDES IN YOUR CITY OR TOWN, IN YOUR JURISTDICTION ONLY.

______

Police Chief or City Hall Officials Signature Date

Three (3) References AND reference letters are required for new AND renewal applications and are to be submitted along with the application. All three references are to TYPE a letter for the applicant pertaining to the gun permit that is SIGNED, DATED AND MUST BE NOTARIZED. Reference letters must be written by the reference, not the applicant, and cannot be identical.

Please list three (3) references:

______

NameAddress/City/State/ZipTelephone NumberYears known

______

NameAddress/City/State/ZipTelephone NumberYears Known

______

NameAddress/City/State/ZipTelephone NumberYears Known

Pawtucket Police Department

NOTE: THE RHODE ISLAND COMBAT COURSE IS FOR LAW ENFORCEMENT PERSONNEL ONLY. ALL OTHERS MUST QUALIFY IN ACCORDANCE WITH (RIGL: 11-47-15).

WEAPONS QUALIFICATION SCORE: CALIBER OF WEAPON: ______

ARMY-L ______SCORE ______R.I. COMBAT ______SCORE ______

______

SIGNATURE OF N.R.A. INSTRUCTOR OR POLICE RANGE OFFICER DATE

______

PRINTED NAME & TELEPHONE NUMBER OF N.R.A. INSTRUCTOR OR POLICE RANGE OFFICER

______

N.R.A NUMBER OR POLICE AGENCY NAME

**********************************************

AFFIDAVIT

I CERTIFY THAT I HAVE READ AND THAT I AM FAMILIAR WITH THE PROVISIONS OF 11-47-1 TO 11-47-62, INCLUSIVE, OF THE GENERAL LAWS OF RHODE ISLAND, 1956, AS AMENDED, AND THAT I AM AWARE OF THE PENALTIES FOR VIOLATIONS OF THE PROVISIONS OF THE CITED SECTIONS. I FURTHER UNDERSTAND THAT ANY ALTERATION OF THIS PERMIT IS JUST CAUSE FOR REVOCATION.

______

Applicant’s SignatureDate

SUBSCRIBED AND SWORN TO BEFORE ME IN ______, RHODE ISLAND

THIS ______DAY OF ______, 20______.

______

Notary Public SignatureNotary Public Printed Name Month/Year/State