2024 Temporary Firearm Permit Instructions 7.19.24

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

YOU MUST BE 21 AND A WATERFORD RESIDENT TO on
TOWN OF WATERFORD
TEMPORARY FIREARM APPLICATION CHECKLIST
READ ALL INSTRUCTIONS CAREFULLY BEFORE SUBMITTING- ALL COPIES WILL BE MADE AT TIME OF SUBMISSION
Please call 860-447-2212 to make an appointment to have your fingerprints taken.
A service code will be given to you at this time. You need this code to complete the next step.
The State of Connecticut does not allow law enforcement agencies to post this code.
Please do not share this code with anyone else.
(This may cause issues for other applicants and cause them to incur extra fees.)
Complete the online pre-enrollment: https://ct.flexcheck.us.idemia.io/CCHRSPreEnroll/
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.
All copies also will be taken at that time:
Completed and NOTARIZED DPS-799-C (Rev. 08/04/2022 Version- OTHER VERSIONS WILL NOT BE ACCEPTED)
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.
If you 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.
Complete BOTH military questions even if you were never in the military.
Birth Certificate OR copy of Passport (You do not need both)
Firearm Safety Course Certificate with the name of applicant:
SEE ATTACHMENTS FOR JULY 1, 2024 REQUIREMENTS FROM CT PUBLIC ACT 23-53
(Must be a Connecticut course, the state does not accept out-of-state courses)
Driver’s License
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.
vY You must reside in Waterford. You CANNOT use a business address on the application.
A fingerprint fee of $15.00 will be collected at the time of fingerprinting. Forms of payment accepted are:
e Check made payable to the Town of Waterford (must have a pre-printed address)
e Money Order made payable to the Town of Waterford
e Cash (exact change-the police department does not have change)
e Credit Card’(4% charge)

According to Connecticut General Statute Chapter 529 Section 29-28a the
local municipality has eight (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). You cannot purchase a
firearm with a temporary firearm permit.
PLEASE NOTE:
IF MORE THAN 3 MONTHS HAS PASSED SINCE YOU RECEIVED THIS PACKET PLEASE GET A
BRAND NEW PACKET FROM THE POLICE DEPARTMENT. THE STATE OF CONNECTICUT
FREQUENTLY UPDATES THE DPS-799-C. IF YOU HAVE THE INCORRECT VERSION YOUR
FINGERPRINTS WILL NOT BE TAKEN AND YOU WILL NEED TO COMPLETE THE FORM IN ITS
ENTIRETY A SECOND TIME INCLUDING THE NOTARY AUTHENTICATION.
Any and all questions can be emailed to janderson@waterfordct.org

Fingerprinting Process Instructions:
© Call the Waterford Police Department at 860-447-2212
and schedule an appointment to get your fingerprints
taken. You will receive a service code* when you make
your appointment.
*YOU NEED A SERVICE CODE BEFORE YOU PRE-ENROLL.
PLEASE DO NOT GIVE THIS CODE TO ANY OTHER
APPLICANTS. IT MAY CAUSE ISSUES WITH THEIR FIREARM
PERMIT PROCESS. THE STATE OF CONNECTICUT
PROHIBITS ANY LAW ENFORCEMENT AGENCY FROM
POSTING THIS CODE FOR THE GENERAL PUBLIC.*
© Go to the link below and pre-enroll BEFORE your
fingerprint appointment:
o https://ct.flexcheck.us.idemia.io/CCHRSPreEnroll
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 applicant tracking 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.
This fee can be paid by:
e Check or Money Order made payable to the Town of Waterford
e Cash (exact change)
e Credit card (4% fee)

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Special Licensing and Firearms Unit
PISTOL PERMIT/ELIGIBILITY CERTIFICATE APPLICATION
(Pursuant to C.G.S. §§ 29-28 et. seg., 29-36 ef. seqg., 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:
60 Day Temporary State Pistol Permit
Non-Resident State Pistol Permit
CL Eligibility Certificate to Purchase Pistols or Revolvers
CL 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 1.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 PACKETTM*
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 l of 4

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Contact / Identifying Information:
Name of Applicant
COCOOOOCOOOOCCOO0COoooo, 2.
LastCIO
Middle initial
Provide ail other names by which you have been known (Maiden name, Allases, Nicknames, atc.)
(Attach additional sheet(s), if necessary)
) Date of Birth Sex Height | Weight e Color
OOOOOOOD | Or Os Ft |(CJLJDtbs.|Cl8rown DBtue [Black
Month/Day/Year [JunknownNonbinary | [IO In. [JGreen [)Gray (Haze!
oI wht Clam T JAsia Seren [1] Black [1] Blonde [1 Red
erican Indian/A! onde
i / scien other. askan Native n/Pacific Islander a Gray oj White cI Bald
Place of Birth Social Security Number (Optional, but will help
DOOD OOOOOOOODOOOOoOon, Oo naetee
City/Town State I i] bl
Allon Reg. Number (if appiicable)
a a la dare Ne ee ign Re ta rn ek a fh Se Pe Pare Rance See — et Pee Pe —nnerd
Residential Address (List street address. Post office box numbers are not Cie
DOLOOOOUEO OCC eon
CIWIOOUCOOOOOOCOROOOOR, OO OOOO
| 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
ec Address ((f different from current residential address above)
CIOOOUOOOOOCODODOInoonnooonooooo
Number/Street
CIDOOOOOODOOOOOOOOOOOD, 00 OOOO
| City/Town State__ Zip Code
Home Telephone Number Motor Vehicle 0, r’s License Number
COO 000-0000 |OOOOOOOCOAoOOoOon on
State of issue
Alternate Telephone Number Email Address
(O00) OOD-OD0O
Area Code
Emptoyment History:
List Emptoyers 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 pormit, permit application or eligibility certificate of any kind from ANY jurisdiction in the
United States denied, suspended or revoked? LINO [IYES
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 iliness In the past sixty (60) months by order of a Probate Court?
LINO [YES 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 gullty of a crime
by reason of a mental disease or defect? [INO [Ives
if "YES," explain: (Attach additional sheet(s), if necessary)
Have you been voluntarily admitted to a hospital for mental ifiness within the past six (6) months for reasons other
than solely for alcohol or drug dependence? [INO [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
fo @ hospital for mental iiiness within the past six (6) months for reasons other than solely for alcoho! or drug dependence.
Criminal History:
Have you ever been ARRESTED for any crimo, in any jurisdiction? LINO LIVES 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 noiled, a criminal charge
bf punch the person has been found not gullty, or a conviction for which the person received an absolute pardon (C.G.S. 54-
).
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?
[INO [YES if "YES," list all convictions, include charges, location, date of arrest, and disposition. (Attach additional
sheet(s), if necessary)
Are you currently on probation, parele, work release, in an aleohol and/or drug treatment program or other pre-trial
diversionary program or cu released on personal recognizance, a written promise to appear or a bail bond for
a pending court case? [INO S_ If "VES," 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? [INO [YES
If “YES,” which court issued the order?
Mill History:
Were you ever a member of the Armed Forces of the United States? [JNO CIYES (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? CINO LIYES
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)
[_INational Riffe Association
popartment of Energy and Environmental Protection (DEEP)
ther:
State Instructor's Name and [D 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 taw (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
sat ement. My signature below attests to the accuracy, completeness and to the truth of all infermation supplied on this
application:
I declare, under the penatities of false statement, that the answers to the above are true and correct.
Date Signed
STATE OF
Print Name
COUNTY OF
Subscribed and swom 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 appitcation 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 (80) 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.
Application Received: FBI Sent: _INo les Application Status:
FBI Reply: [Ino [_lves
DOOD ICE Response: [_]No [ves [lapproved []Dented
Month/Day/Year DMHAS: Eno [ves
SPBL LIne [les (Signature and title of Issuing authority)
rs
DPS-799-C (Rev. 08/04/2022) An Affirmative Action/Equal Bmployment Opportunity Employer Page 4 of 4

Requesting Entity: Waterford Police Department
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
authorities 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 after 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 agencies 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: Waterford Police Department
As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such
as an application for employment or a license, an immigration or naturalization matter, security 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.
* 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 Statement must
explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated
information will be searched, shared, or retained. ”
+ You must be advised in writing of the procedures for obtaining a change, correction, or update of your FBI criminal history record as
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),
+ 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.
* If 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.fbi.gov/services/cjis/identity-
history-summary-checks and https://www.edo.cjis.gov.
* If you 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. Alternatively, you may send your challenge directly to the FBI by
submitting a request via https://www.edo.cjis.gov. The FBI will then forward your challenge to the agency that contributed the
questioned information 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 changes/corrections 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
If you 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)
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 be retained by the Entity.
+ Written notification includes electronic notification, but excludes oral notification.
? See https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(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).

AS OF JULY 1, 2024
(PER CT PUBLIC ACT 23-53)
e ALL FIREARM SAFETY COURSE INSTRUCTORS ARE
REQUIRED TO INCLUDE THE CERTIFICATE OF
COMPLETION WITH EVERY FIREARM SAFETY COURSE
CERTIFICATE*
*Non NRA Instructors still need to fill out Certificate
of Completion. The NRA Instructor ID# can be their
instructor ID#
® SAFETY COURSE CERTIFICATESCANNOTBE OLDER
THAN 2 YEARS**
**The applicant may have to take a new safety
course if their certificate is more than two years old.

STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Special Licensing & Firearms Unit
CERTIFICATE OF COMPLETION
| certify that | instructed the below-named student on the state law
requirements pertaining to: (1) safe storage in the home and in vehicles; (2)
lawful use of firearms; and (3) lawful carrying of firearms in public, in
conformance with Public Act 23-53.
Instructor Name (Printed) Date of Instruction
Instructor Signature NRA Instructor ID#
| certify that the above-named individual instructed me on the state law
requirements pertaining to: (1) safe storage in the home and in vehicles; (2)
lawful use of firearms; and (3) lawful carrying of firearms in public, in
conformance with Public Act 23-53.
Student Name (Printed) Date of Instruction
Student Signature
General: (860) 685-8290 Special Licensing: (860) 685-8160 Fax: (860) 685-8496
1111 Country Club Road
Middletown, CT 06457
www.ct.govu/despp
An Affirmative Action/Equal Opportunity Employer

Substitute House Bill No. 6667
shall issue a long gun eligibility certificate unless said commissioner
finds that the applicant: (1) [Has] (A) For any application filed prior to
uly 1, 2024, has failed to successfully complete a course approved by
the Commissioner of Emergency Services and Public Protection in the
safety and use of firearms including, but not limited to, a safety or
training course in the use of firearms available to the public offered by
a law enforcement agency, a private or public educational institution or
a firearms training school, utilizing instructors certified by the National
Rifle Association or the Department of Energy and Environmental
Protection and a safety or training course in the use of firearms
conducted by an instructor certified by the state or the National Rifle
Association, or (B) for any application filed on or after July 1, 2024, has
failed to successfully complete, not earlier than‘évo vears\prior to the
submission of such application, a course approved by the Commissioner
of Emergency Services and Public Protection in the safety and use of
firearms, which courses may include those certified by the National
Rifle Association or other organizations, conducted by an instructor
certified by the National Rifle Association or by the state, provided any
such course includes instruction in state law requirements pertaining to
safe storage in the home and in vehicles, lawful use of firearms and
lawful carrying of firearms in public; (2) has been convicted of (A) a
felony, (B) a misdemeanor violation of section 21a-279 on or after
October 1, 2015, [or] (C) a misdemeanor violation of section 53a-58, 53a-
61, 53a-61a, 53a-62, 53a-63, 53a-96, 53a-175, 53a-176, 53a-178 or 53a-181d
during the preceding twenty years, or (D) a misdemeanor violation of
any law of this state that has been designated as a family violence crime
pursuant to section 46b-38h; (3) has been convicted as delinquent for the
commission of a serious juvenile offense, as defined in section 46b-120;
(4) has been discharged from custody within the preceding twenty years
after having been found not guilty of a crime by reason of mental disease
or defect pursuant to section 53a-13; (5) has been confined in a hospital
for persons with psychiatric disabilities, as defined in section 17a-495,
within the preceding sixty months by order of a probate court; (6) has
Public Act No. 23-53 67 of 102

This is the {eft half of the NRA logo in light blue/gray
color. Itis only available on certificates available to the
instructor when ne'she logs in his/her NRA account and
enters the necessary information when the course is
The informationinred ,
explains how itis entered
on the certificate. The only
iter that the instructor
must do to compicte this
certificate is to add his/her
completed. If this logo is not on the certificate,
information was not forwarded to NRA which mak
certificate a fake because they may not have foilowed
NR& protocol or the CT State law.
L,
NATIONAL RIFLE ASSOCIATION OF AMERICA
/ certifies that
My As soon as the instructor submits the report to NRA, the: VW,
\ will appear on this certificate and the ce r. 
|
~ instructor can print it for the student.
Vig naleare
IS:
GMM
has successfully completed the
E iT Doesni‘t NAVETN
BASICS OF PISTOL SHOOTING
the student's shooting qualification
i Marksmanship Skill Level: Level 1, 2, 3, or 4 level will automatically be entered here
Level-1: 5 rounds into a 4" circle 4 times at 10 feet
Level-2: § rounds into a 4" circle 4 times at 15 feet
Level-3: 5 rounds into a 4" circle 4 times at 20 feet
Level-4: 16 out of 20 rounds into a 6" circle 1 time at 45 feet
Gnatructors J tgnateee 1234567890 \d . “Ze, _—
INSTRUCTOR SIGNATURE INSTRUCTOR I.D. number will automatically — YSN C. FRAZER, SECRETARY
be printed on the certificate
NAME OF INSTRUCTOR January 1, 2035 NATPONALRIEEE ASSOCIATION j.
INSTRUCTOR PRINTED NAME DATE the course report was submitted to NRA. X
will be automatically printed on the certificate SERIAL NUMBER: 123456
DONT yoy |