Superior Court of the State of Delaware Application for a License to Carry a Concealed Deadly Weapon Please file original and one (1) copy of all documents, together with the filing fee. wo (2) urrent olorhotographs. CCDW License # New Renewal Retired Police Officer County in which you are applying New Castle Kent Sussex Full Name LastFirstMiddleSuffix Address StreetCit y StateZip Phone Numbers HomeWorkCel l Identifying Information US Citizen Yes No Driver222s License or State ID Social Security Number Date of Birth Place of Birth (City)Place of Birth (State) Sex Height WeightEye ColorHair Color Race Employment Information Occupation Employer Phone Name of Employer Employer Address (Place of Business) StreetCit y StateZip Reason for Application (Be VERY Specific) Do you hold a permit in another state? Yes No If yes, which state? Have you ever been denied a permit? Yes No If yes, which state? Date Have you ever been convicted of any alcohol related offense? Yes No If yes, list date(s), place(s) offense(s) and sentence(s) 1 2 Have you ever been convicted 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? Yes No Have you ever been committed for a mental disorder to any hospital, mental institution, or sanitarium? Yes No If yes, do you possess a certificate of a licensed medical doctor or psychiatrist that you no longer suffer from a mental disorder which interferes or handicaps you from handling deadly weapons? (If yes, attach certificate) Yes No 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 Have you ever been, as a juvenile, adjudicated as delinquent for conduct which, if committed by an adult, would constitute a felony? (A response to the question is not required if you have reached your 25th birthday) Yes No IF ADDITIONAL SPACE IS NEEDED, ATTACH A SEPARATE SHEET Revised /201 American LegalNet, Inc. www.FormsWorkFlow.com Declaration and Affirmation of Applicant I Applicant, respectfully state that I am desirous of being licensed to carry a concealed deadly weapon, for the protection of my person or property, or both, and for the particularized need stated in this application. I do hereby declare and affirm under the penalties of perjury that the contents of the foregoing application are true and correct to the best of my knowledge, information, and belief; and I so indicate by signing below in the designated space. I have fulfilled all requirements of this application as instructed. I agree to supply any additional information needed in connection with this application. ANY FALSE INFORMATION WILL BE SUFFICIENT GROUNDS FOR DENIAL OF THIS APPLICATION. Wherefore, Applicant prays that the Superior Court issue a license pursuant to 11 Del. Code 247 1441. Signature of Applicant Date SWORN TO AND SUBSCRIBED BEFORE ME THIS DAY OF A.D., Notary Publi c FOR OFFICIAL USE ONLY Sent to DOJ (Date) Investigator Recommendation Approved Denied Unrestricted Restricted Remarks Reviewer Signature Date Attorney General Recommendation Approved Denied Unrestricted Restricted Remarks Attorney General Signature Date Sent to Judge (Date) Superior Court Recommendation Approved Denied Unrestricted Restricted Remarks Judge222s Signature Date CCDW Permit # SBI # Date Mailed Revised /201 American LegalNet, Inc. www.FormsWorkFlow.com