BFPE: Appellant Questionnaire
Board of Firearms Permit Examiners
BFPE: Appellant Questionnaire

Appellant Questionnaire

 

 

CASE

 

1. NAME   (Circle one)  Mr.  Mrs.  Ms.     

 

______________________________________________________________________

 (First)                                 (Middle Initial)  (Last)

 

2. HOME ADDRESS: 

 

______________________________________________________________________ 

(No. & Street)                          (City or Town)        (State)      (Zip Code)

 

 

3. Mailing Address, if different from home address or the address of your attorney, (optional)

 

______________________________________________________________________

(No. & Street)                              (City or Town)       (State)  (Zip Code)

 

 

4. Are you represented by an attorney? ____________

   If yes, Attorney’s name_________________________

 

5. Telephone number where you can be reached or a message left by the Board office:

     Home (______)______________________

     Work (______)_____________________

     Cell   (______)______________________

 

6. Date of BIRTH (mm/dd/yyyy): _________________________

 

7. Are you a U.S. citizen? _________If naturalized:  When___________Where__________________________

 

8. EMPLOYER:

Name__________________________________________________________________

 

 Address:_______________________________________________________________      

            (No. & Street)             (City or Town)     (State)  (Zip Code)

 

9. Have you ever held a permit or license to carry a pistol or revolver?____________(Yes/No)

If  “Yes” When____________________Where_________________________________

                        (Mo.)                 (Yr.)                  (State)     

 

10. Have you ever filed an appeal with the Board prior to this appeal? ____If so what was the result?

 

 

 

 

-2-

 

NAME_______________

 

If you are appealing a permit REVOCATION, you may skip Questions 11, 12, 13 & 14

 

11. Where did you apply for the permit you are now seeking?

____________________________________________________________________

(Borough, Town,)                   (State)

 

12. What was the date you applied?

       ______________________________________________________________________

 

13.  Give Name of the Police Department or First Selectman to whom you gave your application:

____________________________________________________________________

 

14. Give Name of the Police Department or First Selectman who denied or failed to issue a permit:

       ______________________________________________________________________

 

15. State the reason (s) given to you for the revocation, denial or the failure to issue a permit:

 

 

16. What is the date that you where notified of the denial or revocation:

____________________________________________________________________

   (Month)                  (Day)                         (Year)

 

17. How did you learn of the denial or revocation (Check One):

In Writing________Phone call____________Other____________

 

If “Other”, state how: __________________________________________________________________

 

18. State here any additional facts which would support your case. State what you want the Board to do and why do you feel the Board should grant your request:

 

 

 

 

 

 

 

 

Your signature: __________________________________________Date______________

 

 

 

 

 

 

 

-3-

 

NAME ______________

 

ARREST HISTORY

 

Include all arrests, violations, and infractions within or outside this state.

 

CHARGE                      DISPOSITION             DATE                     TOWN & STATE     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTOR VEHICLE DRIVING HISTORY

 

Include all arrests, violations, and infractions in or out this state.

 

 

CHARGE                      DISPOSITION             DATE                     TOWN & STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The foregoing information is full and complete. I understand that Section 29-29 of the Connecticut General Statutes, as amended, provides that no permit shall be issued unless full information concerning my criminal record (if any) has been given to the issuing authority.

 

_____________________________                   ______________

       Signature of Applicant                                      Date