2023 Temporary Permit Instructions and Application

WATERFORD POLICE DEPARTMENT
41 AVERY LANE
WATERFORD, CT 06385-2819
Marc Balestracci (860) 442-9451 TEL
Police Chief mbalestracci@waterfordct.org
Dear Applicant:
This packet is for a 60-Day Temporary Firearm Permit* with the
Town of Waterford. We have attempted to give as much
instruction as possible to you and account for every scenario of
every applicant.
Please read all of the instructions carefully. Due to the fact
that this process is time consuming and costly we want to do
everything in our power to avoid your application getting
denied.
Thank you,
The Waterford Police Department
*If you are applying for a Non-Resident State Pistol Permit,
Eligibility Certificate to Purchase Pistols or Revolvers or an
Eligibility Certificate to Purchase Long Guns please contact the
State of Connecticut at: SLFU.OOS@ct.gov. The Town of
Waterford DOES NOT process these permits.
www.waterfordpolice.org

©. MUST BE 21 AND A WATERFORD RESIDENT TO APPLY
TOWN OF WATERFORD
TEMPORARY FIREARM APPLICATION CHECKLIST
READ ALL INSTRUCTIONS CAREFULLY BEFORE SUBMITTING
KEEP THESE INSTRUCTIONS FOR FUTURE REFERENCE
© Please call 860-447-2212 to make an appointment to have your fingerprints taken
o Complete the online pre-enrollment: https://ct.flexcheck.us.idemia.io/CCHRSPreEnroll/
o Bring the tracking number email to the fingerprint appointment
ALL paperwork and the fingerprinting fee must be submitted at the time that your fingerprints are taken:
o Completed and NOTARIZED DPS-799-C (2022 Version)
Any incomplete applications will be returned to the applicant for completion. This is a NOTARIZED document and
cannot be altered by anyone except the applicant. This will delay the permit process.
v Ifyou do not know your FULL criminal history, please complete a State Record Check (DPS-0846-C) before
applying. An application without a complete and full criminal history WILL BE DENIED.
Y Complete BOTH military questions even if you were never in the military.
o Copy of Birth Certificate OR copy of Passport (You do not need both)
O°
Copy of Firearm Safety Course Certificate with the name of applicant
(Must be a Connecticut course, the state does not accept out-of-state courses)
()
Copy of Driver’s License
O°
Copy of DD-214 (if applicant was a former member of the Armed Forces of the United States)
°
If the applicant’s license address does not match their current address:
v Please provide a copy of a Town of Waterford tax bill or electric bill.
Y You must reside in town. You CANNOT use a business address on the application.
o Check or money order payable to the Town of Waterford for $15.00 (Fingerprinting Fee)
oO Personal checks MUST have a pre-printed address on them or they will not be accepted
According to Connecticut General Statute Chapter 529 Section 29-28a the local municipality has 8 weeks to
process your temporary firearm permit. These instructions are for your temporary town permit. More fees will be
incurred once you have been approved. ($70.00 to the Town of Waterford and $70.00 to the State of
Connecticut). No firearms can be purchased with a temporary permit.
Any and all questions can be emailed to janderson@waterfordct.org

Fingerprinting Process Instructions:
o Go to the link below and pre-enroll BEFORE your
fingerprint appointment:
o https://ct.flexcheck.us.idemia.io/CCHRSPreEnroll
o Call the Waterford Police Department at 860-447-2212
and schedule an appointment to get fingerprinted.
o Once you have pre-enrolled you will receive an Applicant
Tracking Number via email. Bring this email with the
tracking number with you to your fingerprinting
appointment. Without this number your fingerprints
cannot be taken.
When you get your fingerprints taken at the Waterford Police
Department there will be a $15.00 fingerprinting fee required.
Please make a check or money order payable to the
Town of Waterford.

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Special Licensing and Firearms Unit
PISTOL PERMIT/ELIGIBILITY CERTIFICATE APPLICATION
STATE POLICE
(Pursuant to C.G.S. §§ 29-28 et. seq., 29-36 et. seq., and 53a-217 et. seq.
Before completing this application, it is suggested that you review the Connecticut General Statutes pertaining
to firearms. These can be accessed on the Internet at www.cga.ct.gov. or through your local library.
Type of Permit Requested:
Check Box:
C1 60 Day Temporary State Pistol Permit
(J Non-Resident State Pistol Permit
LJ Eligibility Certificate to Purchase Pistols or Revolvers
L] Eligibility Certificate to Purchase Long Guns
Instructions:
Instructions for State Pistol Permits:
Instructions for Non-Resident
State Pistol Permits:
Instructions for Eligibility
Certificates to Purchase Pistols
or Revolvers and/or Eligibility
Certificates to Purchase Long
Guns:
1. Complete this form (DPS-799-C) and submit to
appropriate local authority (local police, resident
state trooper or first select person, as applicable)
along with all of the following:
= Firearms Safety & Use Course Certificate;
= $70.00 fee, payable to the local authority; and
= Proof you are legally and lawfully in the
United States (e.g., certified copy of birth
certificate, U.S. passport or documentation
issued by I.C.E.).
2. Fingerprints are required to process this
application. Please contact your local law
enforcement agency for further direction on the
process for obtaining fingerprints.
3. Upon approval, the local authority will issue a
Temporary State Permit to Carry Pistols and
Revolvers (DPS-11-C), effective for 60 days.
4. Within the 60 day period, go to a DESPP,
Division of State Police, pistol permit location and
submit the following:
= The Temporary State Permit to Carry Pistols
and Revolvers (DPS-11-C) issued by the
local authority;
= Acompleted Application for State Permit to
Carry Pistols and Revolvers (DPS-46-C);
= $70.00 fee, payable to Treasurer, State of
Connecticut;
» Proof you are legally and lawfully in the
United States (e.g., certified copy of birth
certificate, U.S. passport or documentation
issued by I.C.E.); and
* Proof of valid state issued photo identification
card.
5. Upon approval, your photograph will be taken at
DESPP and you will be issued a state pistol permit.
**CALL DESPP FOR PACKET**
You must hold a valid permit or
license to carry a pistol or revolver
issued by a recognized United States
jurisdiction.
**CALL DESPP FOR PACKET*
You must be 21 years of age to
obtain a Pistol Eligibility Certificate.
You must be 18 years of age to
obtain a Long Gun Eligibility
Certificate.
For Department of Emergency Services and Public Protection (DESPP), Division of State Police, pistol permit locations, access
www.ct.gov/despp and follow the link to the Special Licensing and Firearms Unit or call (860) 685-8290. Note: All payments must
be made with separate checks.
DPS-799-C (Rev. 08/04/2022)
An Affirmative Action/Equal Employment Opportunity Employer
Page 1 of 4

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Contact / Identifying Information:
Name of Applicant
LILO, Co.
EOOOOCOoOOoooooooo
Provide all other names by which you have been known (Maiden name, Aliases, Nicknames, etc.)
(Attach additional sheet(s), if necessary)
Date of Birth Sex Height Weight Eye Color
OIWVOLVOOIW | ir Com Cdr | CILJLdtbs. | (Brown [Blue [Black
Month/Day/Year [_Junknown/Non-binary | [_][ Jin. LC) Green [JGray (Hazel
Race Hair Color
L_Jwhite [American Indian/Alaskan Native [Asian/Pacific Islander L] Brown (] Black [J] Blonde (J Red
[]Btack — [_]Unknown/Other L]Gray [White (] Bald
noc OOOooooooooooooo oo Social Security Number (Optional, but will help
prevent misidentification)
City/Town "State LT tL TI
Country of Citizenship Alien Reg. Number (If applicable)
COLIC | ooo
Residential Address (List street address. Post office box numbers are not acceptable)
AICI
Number/Street
CILIWIOUUUIUI, Os I-00
City/Town State Zip Code
List Residential Addresses for the Last 7 Years (Attach additional sheet(s), if necessary)
“Any subsequent changes of address must be reported within 48 hours to the Special Licensing and Firearms Unit
1
2.
Mailing Address (If different from current residential address above)
KIO RO oooooooooooooo
Number/Street
DIDIOIUOOOOOO000O00000o, 00 Oo0oc-oooo
Home Telephone Number Motor Vehicle Operator's License Wanker Zip Code
(01) DOO-O000 OOOO aan
Alternate Tele phone Number Email Address ate ornseue
(ICC) OO0-O000
Employment History:
List Employers for the Last 7 Years (Provide employer’s name, address and telephone number)
(Attach additional sheet(s), if necessary)
1.
2.
Permit or Eligibility Certificate History:
Have you had a firearms permit, permit application or eligibility certificate of any kind from ANY jurisdiction in the
United States denied, suspended or revoked? [JNO [YES
If “YES,” provide:
1. Identify the jurisdiction which issued the denial, suspension or revocation:
2. Date of denial, suspension or revocation:
3. The reason for the denial, suspension, or revocation:
DPS-799-C (Rev. 08/04/2022) An Affirmative Action/Equal Employment Opportunity Employer Page 2 of 4

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Medical History:
Have you been confined in a hospital for mental illness in the past sixty (60) months by order of a Probate Court?
LINO CLIYES If"YES," explain: (Attach additional sheet(s), if necessary)
Have you been discharged from custody within the past twenty years after having been found not guilty of a crime
by reason of a mental disease or defect? [JNO [LI]YES
If "YES," explain: (Attach additional sheet(s), if necessary)
Have you been voluntarily admitted to a hospital for mental illness within the past six (6) months for reasons other
than solely for alcohol or drug dependence? [JNO [YES
If "YES," explain: (Attach additional sheet(s), if necessary)
Notice: DESPP herein notifies the applicant that, pursuant to C.G.S. §§ 29-28 through 29-38b, DESPP will be notified by
the Department of Mental Health and Addiction Services if the applicant has been confined to a hospital for psychiatric
disabilities within the preceding sixty (60) months by order of Probate Court, or if the applicant has been voluntarily admitted
to a hospital for mental illness within the past six (6) months for reasons other than solely for alcohol or drug dependence.
Criminal History:
Have you ever been ARRESTED for any crime, in any jurisdiction? LINO [JYES If "YES," list all arrests, indicating
charges, locations, dates of arrest and dispositions. (Attach additional sheet(s), if necessary)
Notice: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have
been erased pursuant to C.G.S. §§46b-146, 54-760, or 54-142a. If your criminal records have been erased pursuant to one
of these statutes, you may swear under oath that you have never been arrested. Criminal records that may be erased are
records pertaining to a finding of delinquency or that a child was a member of a family with service needs (C.G.S. 46b-146),
an adjudication as a youthful offender (C.G.S. 54-760), a criminal charge that has been dismissed or nolled, a criminal charge
for which the person has been found not guilty, or a conviction for which the person received an absolute pardon (C.G.S. 54-
142a).
With regard to criminal history information arising from jurisdictions other than the State of Connecticut: You are not required
to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to the
law_of the other jurisdiction. Additionally, you are not required to disclose the existence of an arrest arising from another
jurisdiction if you are permitted under the law of that jurisdiction to swear under oath that you have never been arrested.
Have you ever been CONVICTED under the laws of this state, federal law or the laws of another jurisdiction?
CINO CIYES if "YES," list all convictions, include charges, location, date of arrest, and disposition. (Attach additional
sheet(s), if necessary)
Are you currently on probation, parole, work release, in an alcohol and/or drug treatment program or other pre-trial
diversionary program or currently released on personal recognizance, a written promise to appear or a bail bond for
a pending court case? [INO LJYES If"YES," explain. (Attach additional sheet(s), if necessary)
Within the past five (5) years, have you been the subject of a Protective Order or Restraining Order issued by a court
in a case involving the use, attempted use or threatened use of physical force against another person, regardless of
the outcome or result of any related criminal case? [LINO LIYES
If “YES,” which court issued the order?
Military History:
Were you ever a member of the Armed Forces of the United States? [JNO LIYES (if yes, please include a copy of your DD-214)
Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge? [JNO LJYES
DPS-799-C (Rev. 08/04/2022) An Affirmative Action/Equal Employment Opportunity Employer Page 3 of 4

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Proof of Training:
“Attach a copy of the letter or certificate attesting that you have completed a course in the safety and use of pistols and
revolvers or long guns (as appropriate, depending upon which permit or certificate you are requesting), signed by the instructor
of the course.
Instructor: (Check applicable box)
[National Rifle Association
[_]Department of Energy and Environmental Protection (DEEP)
[Jother:
State Instructor’s Name and ID Number:
Declaration:
| understand that any false statement herein, which | do not believe to be true and which is intended to mislead a public
servant in the performance of his or her official function, is punishable by law (See CGS § 53a-157b). | further understand
that any statement in this application that is determined to be false or inaccurate shall constitute grounds for the denial of
such application. If approved before the facts are known, such approval shall be void if based on a false or inaccurate
statement. My signature below attests to the accuracy, completeness and to the truth of all information supplied on this
application:
| declare, under the penalties of false statement, that the answers to the above are true and correct.
Date Signed
STATE OF
Print Name
COUNTY OF
Subscribed and sworn to before me this day of 20
Name:
Notary Public
My Commission Expires:
Commissioner of Superior Court
NOTICE: Appeal Process for Permits
In the event that your application for pistol permit or eligibility certificate is denied or revoked, you may notify the
Board of Firearm Permit Examiners, at 20 Trinity St., 5" Floor, Hartford, CT 06106. Telephone: (860)256-2977
OR (860) 256-2947, in writing, within ninety (90) days, in order to begin your appeal process. At a hearing
before the Board, you may request that your application be reconsidered or that your permit or eligibility
certificate be reinstated.
_. __. For Official Use Only:
Application Received: FBI Sent: [JNo [Yes Application Status:
FBI Reply: [No L]yes
TIC LILI ICE Response: [_]No [_]Yes [JApproved [_]Denied
onth/Day/Year DMHAS: LIno Llyes
SPBI: LJno L]yes (Signature and title of issuing authority)
Number :
DPS-799-C (Rev. 08/04/2022) An Affirmative Action/Equal Employment Opportunity Employer Page 4o0f4

Requesting Entity:
FBI Privacy Act Statement
Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is
generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authoritics include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders,
and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to
do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances. may be
predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics
may be provided to the employing, investigating. or otherwise responsible agency, and/or the FBI for the
purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI)
system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available
records of the employing, investigating. or otherwise responsible agency. The FBI may retain your fingerprints
and associated information/biometrics in NGI afer the completion of this application and, while retained, your
fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and
associated information/biometrics are retained in NGI. your information may be disclosed pursuant to your
consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable
Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI
system and the FBI’s Blanket Routine Uses. Routine uses include. but are not limited to, disclosures to:
employing, governmental or authorized non-governmental agencies responsible for employment. contracting,
licensing, security clearances, and other suitability determinations: local. state, tribal, or federal law
enforcement agencies; criminal justice agencies; and agencics responsible for national security or public safety.
As of 03/30/2018
Note: This privacy act statement is located on the back of the FD-258 fingerprint card.
SIGNATURE DATE
This document must be retained by the Entity,

Noncriminal Justice Applicant’s Privacy Rights
Requesting Entity:
As an applicant who is the subject of a national fingerprint-based criminal history record chee
as an application for employment or a license, an immigration or naturalization matte curily clearance, or adoption), you have
certain rights which are discussed below, All notices must be provided to you in writing. | These obligations are pursuant to the
Privacy Act of 1974, Title 5. United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12.
among other authorities.
for a noncriminal justice purpose (such
* You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later), by the agency that will receive your
criminal history results, when you submit your fingerprints and associated personal information. This Privacy Act Sutement must
explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated
information will be searched. shared, ar retained. 7
+ You must be advised in writing of the procedures for obtaining a change, correction, or updi
set forth at 28 CFR 16.34.
+ You must be provided the opportunity to complete or challenge the accuracy of the information in your FBI criminal history record
(if you have such a record).
ute of your FBI criminal history record as
+ If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or
decline to do so) before the officials deny you the employment, license, or other benefit based on information in the FBI criminal
history record.
* [f agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible
challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting
fingerprints and a fee to the FBI. Information regarding this process may be obtained at https:/www.lbi.gov/services/ejis/identity-
history-summary-checksand hups:/'www.cdo.cjis.gov.
+ Ifyou decide to challenge the accuracy or completeness of your FBI criminal history record. you should send your challenge to the
agency that contributed the questioned information to the FBI. Altematively. sou may send your challenge directly 10 the FBI by
submitting a request via hitps://www.cdo.cjis.gov. The FBI will then fonvard your challenge to the agency that contributed the
questioned infonnation and request the agency to verify or correct the challenged entry. Upon receipt of an official communication
from that agency. the FBI will make any necessary changescorrections to your record in accordance with the information supplied by
that agency. (See 28 CFR 16.30 through 16.34.)
+ You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized
purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or
standard established by the National Crime Prevention and Privacy Compact Council.’
Updated 11/6/2019
Ifyou need additional information or assistance, please contact:
Connecticut Records: Out-of-State Records:
Department of Emergency Services and Public Protection State Agency of Record
Police Bureau of Identification (SPBI) OR
1111 Country Club Road FBI CJIS Division-Summary Request
Middletown, CT 06457 1000 Custer Hollow Road
860-685-8480 Clarksburg, West Virginia 26306
SIGNATURE DATE
This document must he
* Written notification includes electronic notification, but excludes oral notification,
*See hitps:/Avww.fbi.gov/services/ejis/compact-counciVprivacy-act-statement
> See 5 U.S.C. 552a(b); 28 U.S.C. $34(b); 34 U.S.C. $ 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d)
and 906.2(d).