IT IS THE RESPONSIBILITY OF THE LICENSING AUTHORITY TO ENSURE THE IDENTITY OF THE NEW/RENEWAL APPLICANT IS

TRUE AND ACCURATE, AND IN THE CASE OF A RENEWAL, THAT THE APPLICANT IS LINKED TO THE ORIGINAL TRACKING

NUMBER.

F (__ __ __) __ __ __ __ __ __ __ __ __ (__ __ __) __ __ __ __ __ __ __ __ __

City/Town 9 Digit License Number City/Town 9 Digit License Number

ACT OF 1998, WHICH WENT INTO EFFECT ON OCTOBER 21, 1998.

PLEASE COMPLETE THIS APPLICATION FORM AND TAKE IT TO YOUR LOCAL LICENSING AUTHORITY. (LOCAL POLICE

DEPARTMENT). DO NOT MAIL TO THE FIREARMS RECORD BUREAU.

PLEASE CHECK ONE:

[ ] NEW APPLICANT

[ ] RENEWAL – MOST RECENT LICENSE TO CARRY/FID CARD NUMBER ___________________

ISSUED FROM WHICH CITY/TOWN?___________________________, MA EXPIRATION DATE _________________

CHECK THE TYPE OF LICENSE YOU ARE APPLYING FOR:

[ ] FIREARMS IDENTIFICATION CARD RESTRICTED (MACE/PEPPER SPRAY)

[ ] FIREARMS IDENTIFICATION CARD

[ ] CLASS B LICENSE TO CARRY FIREARMS NON-LARGE CAPACITY

[ ] CLASS A LICENSE TO CARRY FIREARMS LARGE CAPACITY

[ ] LICENSE TO POSSESS A MACHINE GUN

POLICE DEPARTMENT.

ISSUANCE AND REASON MUST ACCOMPANY THIS APPLICATION.

/ /

LAST NAME FIRST NAME MIDDLE NAME

/( )

RESIDENTIAL ADDRESS (Include Number, Street, City/Town, Zip Code) TELEPHONE NUMBER

/( )

IF CLUB LICENSE ADDRESS OF CLUB (Include Number, Street, City/Town, Zip Code) TELEPHONE NUMBER

/ / /

DATE OF BIRTH PLACE OF BIRTH MOTHER'S MAIDEN NAME FATHER'S FULL NAME

FT IN / / / / /

HEIGHT WEIGHT BUILD COMPLEXION HAIR COLOR EYE COLOR

/ /

OCCUPATION S. S. NUMBER (Optional) DRIVER’S LICENSE NUMBER

/ /( )

EMPLOYED BY (SEE # 3 ABOVE) ADDRESS TELEPHONE NUMBER

[ ] CHECK IF CLASS A CLUB LICENSE *

* NOTE: ONLY THE COLONEL OF THE

MASSACHUSETTS STATE POLICE CAN ISSUE A

CLUB LICENSE.

Page 2 of 4

SPACE FOR EXPLANATION AND DETAILS ARE PROVIDED ON PAGE 3.

1. ARE YOU A CITIZEN OF THE UNITED STATES? ___________.

IF NATURALIZED GIVE DATE, PLACE AND NATURALIZATION NUMBER:_____________________________.

2. HAVE YOU EVER USED OR BEEN KNOWN BY ANOTHER NAME? ___________. IF YES PROVIDE NAME AND

EXPLAIN:___________________________________________________________________________________________

THAN 18 YEARS OF AGE WITH SUBMISSION OF A CERTIFICATE FROM PARENT OR GUARDIAN GRANTING PERMISSION

TO APPLY FOR A FIREARMS IDENTIFICATION CARD.

4. HAVE YOU EVER BEEN CONVICTED OF A FELONY? __________

5. HAVE YOU EVER BEEN CONVICTED OF THE UNLAWFUL USE, POSSESSION, OR SALE OF NARCOTIC OR HARMFUL

DRUGS AS DEFINED IN M.G.L. c. 94C, § 1? __________

6. HAVE YOU EVER BEEN CONVICTED OF A CRIME PUNISHABLE BY INCARCERATION BY MORE THAN (1) ONE YEAR?

___________

7. IN ANY STATE OR FEDERAL JURISDICTION HAVE YOU EVER BEEN CONVICTED AS AN ADULT OR ADJUDICATED A

YOUTHFUL OFFENDER OR DELINQUENT CHILD FOR THE COMMISSION OF (a) A FELONY; (b) A MISDEMEANOR

PUNISHABLE BY IMPRISONMENT FOR MORE THAN 2 YEARS; (c) A VIOLENT CRIME AS DEFINED IN M.G.L. c. 140, § 121;

(d) A VIOLATION OF ANY LAW REGULATING THE USE, POSSESSION, OWNERSHIP, SALE, TRANSFER, RENTAL, RECEIPT

OR TRANSPORTATION OF WEAPONS OR AMMUNITION FOR WHICH A TERM OF IMPRISONMENT MAY BE IMPOSED;

OR (e) A VIOLATION OF ANY LAW REGULATING THE USE, POSSESSION OR SALE OF CONTROLLED SUBSTANCES AS

DEFINED IN M.G.L. c. 94, § 1? __________

8. HAVE YOU EVER BEEN CONFINED TO ANY HOSPITAL OR INSTITUTION FOR MENTAL ILLNESS? ________

9. ARE YOU OR HAVE YOU EVER BEEN UNDER TREATMENT FOR OR CONFINEMENT FOR DRUG ADDICTION OR HABITUAL

DRUNKENNESS? __________

10. HAVE YOU EVER APPEARED IN ANY COURT AS A DEFENDANT FOR ANY CRIMINAL OFFENSE (EXCLUDING NONCRIMINAL

TRAFFIC OFFENSES)? __________

11. ARE YOU NOW UNDER ANY CHARGE(S) FOR ANY OFFENSE(S) AGAINST THE LAW? __________

12. ARE YOU NOW OR HAVE YOU EVER BEEN THE SUBJECT OF A M.G.L. c. 209A RESTRAINING ORDER OR INVOLVED IN A

DOMESTIC VIOLENCE CHARGE? __________

13. HAS ANY LICENSE TO CARRY FIREARMS, PERMIT TO POSSESS FIREARMS, OR FIREARMS IDENTIFICATION CARD

ISSUED TO YOU UNDER THE LAWS OF ANY STATE, TERRITORY OR JURISDICTION EVER BEEN SUSPENDED, REVOKED

OR DENIED? __________

14. ARE YOU CURRENTLY THE SUBJECT OF ANY OUTSTANDING ARREST WARRANT IN ANY STATE OR FEDERAL

JURISDICTION? __________

Continued on page 3

*WARNING* ANY PERSON WHO KNOWINGLY FILES AN APPLICATION CONTAINING FALSE

INFORMATION SHALL BE PUNISHED BY A FINE OF NOT LESS THAN $500 NOR

MORE THAN $1,000 OR BY IMPRISONMENT FOR NOT LESS THAN 6 MONTHS

NOR MORE THAN 2 YEARS IN A HOUSE OF CORRECTION, OR BY BOTH SUCH

FINE AND IMPRISONMENT (M.G.L. c.140, § 131).

Page 3 of 4

NAME __________________________________ DOB: _____________

IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS FOUR THROUGH FOURTEEN, GIVE DETAILS WHICH MUST INCLUDE

DATES, CIRCUMSTANCES AND LOCATION:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

(IF NECESSARY USE SEPARATE SHEET OF PAPER TO COMPLETE)

OTHER THAN MASSACHUSETTS, WHAT OTHER STATE, TERRITORY OR JURISDICTION HAVE YOU RESIDED IN?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

HAVE YOU EVER HELD A LICENSE TO CARRY IN ANY OTHER STATE, TERRITORY OR JURISDICTION? __________

IF "YES", WHEN, WHERE AND LICENSE NUMBER:

______________________________________________________________________________________________________

LIST NAME AND ADDRESSES OF TWO REFERENCES (NOT REQUIRED IF APPLYING FOR A FIREARMS IDENTIFICATION

CARD):

1._____________________________________________________________________________________________________

______________________________________________________________________________________________________

2._____________________________________________________________________________________________________

______________________________________________________________________________________________________

REASON (S) FOR REQUESTING THE ISSUANCE OF CARD OR LlCENSE:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

_____

Continued on the reverse side (page 4)

Page 4 of 4

MASSACHUSETTS GENERAL LAW REQUIRES THAT:

ANY LICENSEE SHALL NOTIFY, IN WRITING, THE LICENSING AUTHORITY WHO ISSUED SAID

LICENSE, THE CHIEF OF POLICE INTO WHOSE JURISDICTION THE LICENSEE MOVES AND THE

EXECUTIVE DIRECTOR OF THE CRIMINAL HISTORY SYSTEMS BOARD OF ANY CHANGE OF

ADDRESS. SUCH NOTIFICATION SHALL BE MADE BY CERTIFIED MAIL WITHIN 30 DAYS OF ITS

OCCURRENCE. FAILURE TO SO NOTIFY SHALL BE CAUSE FOR REVOCATION OR SUSPENSION OF

A CARDHOLDER SHALL NOTIFY, IN WRITING, THE LICENSING AUTHORITY THAT ISSUED SUCH

CARD, THE CHIEF OF POLICE INTO WHOSE JURISDICTION SUCH CARDHOLDER MOVES AND THE

EXECUTIVE DIRECTOR OF THE CRIMINAL HISTORY SYSTEMS BOARD OF ANY CHANGE OF

ADDRESS. SUCH NOTIFICATION SHALL BE MADE BY CERTIFIED MAIL WITHIN 30 DAYS OF ITS

OCCURRENCE. FAILURE TO SO NOTIFY SHALL BE CAUSE FOR REVOCATION OR SUSPENSION OF