SP-248 (-2017) FILE NUMBER: APPLICATION FOR CONCEALED HANDGUN PERMIT COMMONWEALTH OF VIRGINIA VIRGINIA CODE SECTIONS 18.2-308.02 AND 06 RESIDENT PERMIT NONRESIDENT PERMIT RENEWAL SEE NOTICE 2 PAGE 3 1. FULL LEGAL NAME (ATTACH A SEPARATE LISTING OF ANY ADDITIONAL NAMES YOU MAY HAVE USED OR BEEN KNOWN BY) FIRST MIDDLE LAST 2. DATE OF BIRTH (YOU MUST BE AT LEAST 21 YEARS OF AGE) MONTH DAY YEAR 3. RESIDENTIAL ADDRESS (ATTACH A SEPARATE LISTING OF ALL ADDRESSES WITHIN THE LAST 5 YEAR PERIOD) STREET OR RURAL ROUTE CITY COUNTY STATE ZIP MAILING ADDRESS (IF DIFFERENT) EMAIL (OPTIONAL) CHECK THIS BOX AND PROVIDE AN EMAIL ADDRESS ABOVE TO REQUEST ELECTRONIC NOTICE IN ADVANCE OF PERMIT EXPIRATION. ( RESIDENT PERMITS ONLY) 4. PHYSICAL FEATURES HEIGHT WEIGHT SEX RACE HAIR COLOR EYE COLOR SCARS , MARKS , TATTOOS , PECULIAR CHARACTERIS TICS : 5. SOCIAL SECURITY NUMBER (OPTIONAL) SEE NOTICE 1 ON PAGE 3 6. PLACE OF BIRTH (LOCALITY/STATE/NATION) COUNTRY OF CITIZENSHIP (YOU MUST BE A UNITED STATES CITIZEN OR HAVE LAWFUL PERMANENT RESIDENCE. NON-CITIZEN APPLICANTS MUST PROVIDE A VALID INS-ISSUED ALIEN REGISTRATION NUMBER.) UNITED STATES OTHER : ALIEN REGISTRATION N UMBER : 7. TELEPHONE NUMBER HOME OTHER 8.CHECK YES OR NO FOR EACH OF THE FOLLOWING QUESTIONS A . 1. HAVE YOU EVER BEEN CONVICTED OF A FELONY OFFENSE ? ( INCLUDE FELONY CONVICTIONS OF DRIVING UNDER THE INFLUENCE AND / OR ANY OFFENSE FORWHICH YOU WERE CONVICTED AS A JUVENILE, WHICH WOULD HAVE BEEN A FELONY IF COMMITTED BY AN ADULT. IF YES, COMPLETE FORM 1 PART B PAGE 2. FAILURE TO ACKNOWLEDGE A CONVICTION MAY BE CONSTRUED AS MAKING A MATERIALLY FALSE STATEMENT. YES NO 2 . HAVE YOU BEEN CONVICTED OF A MISDEMEANOR OFFENSE WITHIN THE FIVE - YEAR PERIOD IMMEDIATELY PRECEDING THIS APPLICATION ? ( INCLUDE MISDEMEANOR CONVICTIONS OF DRIVING UNDER THE INFLUENCE. DO NOT INCLUDE TRAFFIC INFRACTIONS OR THOSE MISDEMEANORS SET FORTH IN TITLE46.2 CODE OF VIRGINIA.) IF YES, COMPLETE FORM 1 PART B PAGE 2. FAILURE TO ACKNOWLEDGE A CONVICTION MAY BE CONSTRUED AS MAKING A MATERIALLY FALSESTATEMENT. YES NO B . HAVE YOU BEEN COMMIT TED TO THE CUSTODY O F THE COMMISSIONER O F BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES ? IF YES, COMPLETE FORM 2 PART A PAGE 2 ( SEE NOTICE 4 PAGE 3) YES NO C . HAVE YOU BEEN ACQUITTED BY REASON OF INSANITY , ADJUDICATED LEGALLY INCOMPETENT , MENTALLY INCAPACITATED OR ADJUDICATED AN INCAPACITATED PERSON BY A COURT OF VIRGINIA OR ANY OTHER COURT? IF YES, COMPLETE FORM 2 PART B PAGE 2. ( SEE NOTICE 4 PAGE 3) YES NO D . HAVE YOU BEEN INVOLUNTARILY ADMITTED TO A FACILITY OR ORDERED TO MANDATORY OUTPATIENT TREATMENT , OR WERE YOU THE SUBJECT OF A TEMPORARY DETENTION ORDER PURSUANT TO VA. CODE 247 37.2-809 WHO LATER AGREED TO VOLUNTARY ADMISSION UNDER VA. CODE 247 37.2-805? IF YES, COMPLETE FORM 2 PAGE 2 AS INDICATED BELOW. ( SEE NOTICE 4 PAGE 3) 1.COMPLETE PART C OF FORM 2 PAGE 2 IF INVOLUNTARILY ADMITTED 2.COMPLETE PART D OF FORM 2 PAGE 2 IF ORDERED TO MANDATORY OUTPATIENT TREATMENT 3. COMPLETE PART E OF F ORM 2 PAGE 2 IF VOLUNTARILY ADMIT TED SUBSEQUENT TO A TEM PORARY DETENTION ORD ER YES NO E . HAVE YOU RECEIVED MENTAL HEALTH TREATMENT OR SUBSTANCE ABUSE TREATMENT IN A RESIDENTIAL SETTING WITHIN THE FIVE YEARS PRIOR TO THE DATE OF THIS APPLICATION? YES NO F . ARE YOU THE SUBJECT OF , OR NAMED AS A RESPONDENT IN A RESTRAINING ORDER OR A PROTECTIVE ORDER ? AN ACTIVE RESTRAINING OR PROTECTIVE ORDER MAY BE AN AUTOMATIC DISQUALIFIER IN VIRGINIA . SEE VA . CODE 247 18.2 - 308.1:4. YES NO G . ARE YOU ADDICTED TO , OR AN UNLAWFUL USER OR DISTRIBUTOR OF MARIJUANA OR ANY CONTROLLED SUBSTANCE ? YES NO H . ARE YOU AN ALIEN NOT LAWFULLY ADMITTED FO R PERMANENT RESIDENC E IN THE UNITED STATES ? YES NO I . HAVE YOU BEEN DISCHARGED FROM THE ARMED FORCES OF THE UNITED STATES UNDER DISHONORABLE CONDITIONS ? YES NO J . ARE YOU A FUGITIVE FROM JUSTICE ? YES NO K . DO YOU HAVE ANY CRIMINAL CHARGE PENDING ? IF YES , COMPLETE FORM 1 PART A PAGE 2. FAILURE TO ACKNOWLEDGE A PENDING CHARGE MAY BE CONSTRUED AS MAKING A MATERIALLY FALSE STATEMENT. YES NO L . HAVE YOU , WITHIN THE THREE - YEAR PERIOD IMMEDIATELY PRECEDING THE DATE OF THIS APPLICATION , EITHER 1) BEEN FOUND GUILTY OF ANY DRUG - RELATED CRIMINAL OFFENSE AS SET FORTH IN ARTICLE 1 (247 18.2-247 ET SEQ.) OF CHAPTER 7 OF TITLE 18.2 OR OF A CRIMINAL OFFENSE FOR THE ILLEGAL POSSESSION OR DISTRIBUTION OF MARIJUANA OR ANY CONTROLLED SUBSTANCE UNDER THE LAWS OF VIRGINIA, ANY OTHER STATE, THE DISTRICT OF COLUMBIA, OR THEUNITED STATES OR ITS TERRITORIES; OR 2) BEEN CHARGED WITH ANY OFFENSE ENUMERATED IN THIS PARAGRAPH AND THE TRIAL COURT FOUND THE FACTS OF THE CASE WERE SUFFICIENT FOR A FINDING OF GUILT AND DISPOSED OF THE CASE PURSUANT TO 247 18.2-251 OR SUBSTANTIALITY SIMILAR LAW OF VIRGINIA, ANY OTHER STATE , THE DISTRICT OF COLU MBIA , OR THE UNITED STATES OR ITS TERRITORIES ? IF YES , COMPLETE FORM 1 PART A OR B PAGE 2. YES NO M . DO YOU CURRENTLY HAVE A VALID RESIDENT CONCEALED HANDGUN PERMIT ISSUED BY A VIRGINIA CIRCUIT COURT ? IF YES , NAME OF THE CIRCUIT COURT WHICH ISSUED THE PER MIT : EXPIRATION DATE YES NO 9. ATTACH A PHOTOCOPY O F THE DOCUMENTATION THAT DEMONSTRATES YO UR COMPETENCE WITH A HANDGUN ( INITIAL PERMITS ONLY ). I, THE UNDERSIGNED, AFFIRM THAT THE INFORMATION CONTAINED IN THIS APPLICATION AND IN ANY ATTACHMENTS TO THIS DOCUMENT IS B OTH CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE. THE WILLFUL MAKING OF A FALSE STATEMENT IN THIS APPLICATION CONSTITUTES PERJURY AND IS PUNISHABLE IN ACCORDANCE WITH 24718.2-434 OF THE CODE OF VIRGINIA. I ALSO AFFIRM AND UNDERSTAND THAT THE ISSUANCE OF A CONCEALE D HANDGUN PERMIT DOES NOT NECESSARILY ENTI TLE ME , THE UNDERSIGNED , TO POSSESS , TRANSPORT OR SELL A FIREARM UNDER STATE OR FE DERAL LAW . Signature of Applicant Date American LegalNet, Inc. www.FormsWorkFlow.com FORM 1 PART A PENDING CHARGES (FOR ADDITIONAL PENDING CHARGES, USE A PIECE OF PLAIN PAPER AND ATTACH) DESCRIBE THE PENDING CRIMINAL CHARGE AGAINST YOU : DATE OF CHARGE : COUNTY , CITY AND STATE OF CHARGE : CURRENT STATUS OF CHARGE : PART B CONVICTIONS (FOR ADDITIONAL CONVICTIONS, USE A PIECE OF PLAIN PAPER AND ATTACH) DESCRIBE THE CHARGE FOR WHICH YOU WERE CONVICTED : DATE OF CONVICTION : COUNTY , CITY AND STATE OF CHARGE : HAVE YOU RECEIVED A PARDON OR RESTORATION OF RIGHTS THAT INCLUDES YOUR FIREARM RIGHTS ? YES NO IF YES , ATTACH SUPPORTING DO CUMENTATION . HAVE YOU BEEN CONVICTED / ADJUDICATED OF AN OFFENSE AS A JUVENILE WHICH WOULD HAVE BEEN A FELONY IF COMMITTED BY AN ADULT? YES NO IF YES , HAVE YOU COMPLETED A TERM OF SERVICE OF NO LESS THAN TWO YEARS IN THE ARMED FORCES OF THE UNITED STATES? ATTACH SUPPORTING DOCUMENTATION. YES NO DID YOU RECEIVE AN HONORABLE DISCHARGE YES NO NOT APPLICABLE FORM 2 PART A COMMITMENTS TO THE COMMISSIONER OF HEALTH AND DEVELOPMENTAL SERVICES DATE OF COMMITMENT : DATE YOU WERE RELEASED FROM CUSTODY : NAME OF COURT WHICH ENTERED THE ORDER : LOCATION OF COURT ( INCLUDE STREET ADDRESS , CITY , COUNTY , AND STATE ) HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT ? YES NO IF YES, HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION? YES NO IF YES , ATTACH SUPPORTING DO CUMENTATION . PART B ADJUDICATION OF LEGAL INCOMPETENCE OR MENTAL INCAPACITATION DATE OF ADJUDICATION : NAME OF COURT WHICH ENTERED THE ORDER : LOCATION OF COURT ( INCLUDE STREET ADDRESS , CITY , COUNTY , AND STATE ) HAS YOUR COMPETENCY OR CAPACITY HAS BEEN RESTORED BY A COURT ? YES NO IF YES, HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION? YES NO IF YES , ATTACH SUPPORTING DO CUMENTATION . PART C INVOLUNTARY ADMISSIONS DATE INVOLUNTARILY ADMITTED : DATE RELEASED FROM THIS ADMISSION : NAME OF COURT WHICH ENTERED THE ORDER : LOCATION OF COURT ( INCLUDE STREET ADDRESS , CITY , COUNTY , AND STATE ) HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT ? YES NO IF YES, HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION? YES NO IF YES , ATTACH SUPPORTING DO CUMENTATION . PART D MANDATORY OUTPATIENT TREATMENT DATE ORDERED TO MANDATORY OUTPATIENT TREATMENT : DATE RELEASED FROM MANDATORY OUTPATIENT TREATMENT : NAME OF COURT WHICH ENTERED THE ORDER : LOCATION OF COURT ( INCLUDE STREET ADDRESS , CITY , COUNTY , AND STATE ) HAVE YOUR FIREARM