SUPERIOR COURT OF THE STATE OF DELAWARE AFFIDAVIT AND PETITION FOR RENEWAL OF LICENSE TO CARRY A CONCEALED DEADLY WEAPON (Please file original and one (1) copy of all documents between January 1 and June 1, together with $34.50 filing fee. Also attach two (2) curre nt 2 x 2 color passport-style p hotographs.) New Castle County Prothonotary 500 N. King Street, Suite 1500 Wilmington, DE 19801-3704 (302) 255-0556 Kent County Prothonotary 38 The Green Dover, DE 19901 (302) 739-3184 ext. 123 Restricted ____________ Sussex County Prothonotary 1 The Circle, Suite 2 Georgetown, DE 19977 (302) 856-5799 (1) Current License#______________ Unrestricted (2) Applican t's Name__________ _____________ _____________ _Telephone No. (3) Date of Birth:________ _____________ ____Place of Birth: (4) Citizenship:_______ _____________ _______Occup ation: (5) Employer: (6) Have you been denied a permit? (7) Have you been convicted of any alcohol related offense during the last 3 years? (Give full details) (8) Have you ever been convicte d in this State or elsewhere of a felony or a crime of violence involving physical injury to another, whether or not armed with or having in your possession any weapon during the commission of such felony or crime of violence? (9) ______________Yes ____________No Have you ever been committed for a mental disorder to any hospital, mental institution, or sanitarium? __________Yes __________No If yes, do yo u possess a certificate of a medical doctor or psychiatrist licensed in this State that you no longer suffer from a mental disorder which interferes or handicaps you from handling deadly weapons? __________Yes __ ________No (If yes, attach a c opy of the certificate.) (10) Have you ever been convicted for the unlawful use, possession, or sale of a narcotic, dangerous drug, or central nervous system depressant or stimulant? __________Yes __________No (11) Have you ever been, as a juvenile, adjudicated as delinquent for condu ct which, if committed b y an adult, would constitute a felony?__________Yes __________No (A response to this question is not required if you have reach ed your 25th birthday .) (12) Do you hold a permit in any other State? ________? If yes, which State __________________________. American LegalNet, Inc. www.USCourtForms.com TO THE JUDGE OF THE SUPERIOR COURT OF THE STATE OF DELAWARE IN AND FOR ________________ COUNTY: The undersigned Petitioner, who resides at _____________________________________________________ Street Address _________________________________ in _____________ __________Co unty, holds a valid Delaware permit to carry City Zip Code a concealed deadly weap on and desires to renew b ecause carrying said wea pon is necessary for the protec tion of petitioner's person or property or both. Petitioner swears that the answers to the above questions are true and correct. Petitioner therefore requests that petitioner 's application be approved and a license be issued for the period of three (3) years beginning___________________. _______________ Date Signature of Petitioner SWORN TO AND SUBSCRIBED BEFORE ME THIS _________ DAY OF _________________ A.D. ________ Notary Public 444444444444444444444444444444444444444444444444444444444444444444444444444444444444U FOR OFFICIAL USE ONLY Reviewer Recommendation Superior Co urt Approved________ Denied_________ Unrestricted____ Restricted_____ Remarks_________________________ ________________________________ Approved___________ Denied_________ Unrestricted_______ Restricted_____ Remarks____________________________ __________________________________ By______________________________ By_________________________________ Judge Renewal of C CDW P ermit form Rev. 4/29/05 American LegalNet, Inc. www.USCourtForms.com