Temporary Pistol Permits (PDF)

WATERFORD POLICE DEPARTMENT
41 AVERY LANE
WATERFORD, CT 06385-2819
Marc Balestracci (860) 442-9451 TEL
Chief of Police mbalestracci@waterfordct.org
0 Please call 860-447-2212 to make an appointment to have your fi ingerprints taken
oO
Complete the online pre-enrollment:
0 Bring printed tracking number email to 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 (2021 Version)
Any incomplete applications will be returned to the applicant for completion.
This will delay the permit process.
This is a NOTARIZED document and cannot be altered by anyone except the applicant
o
Copy of Birth Certificate OR copy of Passport (You do not need both)
Copy of Firearm Safety Course Certificate with name of applicant
(Must be a Connecticut course, the state does not accept out-of-state courses)
Copy of Driver's License
Copy of DD-214 (if. applicant was a member of the Armed Forces of the United States)
Copy of Town of Waterford tax bill or electric bill (If applicant has out-of-state license)
Check or money order payable to the Town of Waterford for $15.00 (Fingerprinting Fee)
Checks must have a pre-printed address on them or they will not be accepted
CASH WIL T CC
oO
oO Oo 0 OO
According to Connecticut General Statute Chapter 529 Section 29-28a the local municipality has
; <s to process your temporary firearm permit
These instructions are for your temporary town permit.
More fees will be incurred once © you have been approved ©
You cannot purchase a firearm with a temporary permit.
Any and all questions can be emailed to janderson@waterfordct.org
www.waterfordpolice.org

Fingerprinting Process Instructions:
o Call the Waterford Police Department at 860-447-2212
and schedule an appointment to get fingerprinted.
o Goto 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 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. Cash is not accepted.

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. seq., 29-36 et. seq., and 53a-217 et. seq.
STATE POLICE
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:
CL] 60 Day Temporary State Pistol Permit
CJ Non-Resident State Pistol Permit
L Eligibility Certificate to Purchase Pistols or Revolvers
L] Eligibility Certificate to Purchase Long Guns
Instructions:
Instructions for Eligibility
Instructions for Non-Resident Certificates to Purchase Pistols
Instructions for State Pistol Permits: State Pistol Permits: or Revolvers and/or Eligibility
Certificates to Purchase Long
Guns:
1. Complete this form (DPS-799-C) and submit to **CALL DESPP FOR PACKET** **CALL DESPP FOR PACKET*
appropriate local authority (local police, resident | You must hold a valid permit or You must be 21 years of age to
State trooper or first select person, as applicable) | license to carry a pistol or revolver obtain a Pistol Eligibility Certificate.
along with all of the following: issued by a recognized United States | You must be 18 years of age to
« Firearms Safety & Use Course Certificate; jurisdiction. obtain a Long Gun Eligibility
= $70.00 fee, payable to the local authority; and Certificate.
» 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.
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
COULD, 6.
EOOCOOOOeO Oooo
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
Oooooooo [Je Ju [_ |Ft. [JL JL |tbs. | LJ) Brown [Blue [Black
Month/Day/Year [_Junknown/Non-binary | [_ |[_]in. [J Green [)Gray (Hazel
Race Hair Color
[|wnite [American Indian/Alaskan Native [_]Asian/Pacific Islander L] Brown [] Black [] Blonde [] Red
[_|Black — [_]Unknown/Other LJ Gray []White (Bald
noc qooooooooooooood qo Social Security Number (Optional, but will help
prevent misidentification)
City/Town sate |THE EE EE
Country of Citizenship Alien Reg. Number (If applicable)
DODODOOOODODOOOOOoon §$_ |
Residential Address (List street address. Post office box numbers are not acceptable)
LILILIDUULUIOOIODOILOO
AIC IOS, oO Goooc-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
1
2.
Mailing Address (|f different from current residential address above)
AIO ooo
Number/Street
TILL, Oo o-oo
City/Town State Zip Code
Home Telephone Number Motor Vehicle Operator’s License Number
(QOD) OOO-O000 ;OOOIOUIOIOIOIIIs LI
Area Code State of Issue
Alternate Telephone Number Email Address
(00) OOOO
Area Code
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 [LJYES
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 [LIYES 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 LIYES
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 [JYES
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
toa 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? [JNO [LIYES [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?
LINO LIYES 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? JNO [JYES 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? [INO [JYES
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 LIJYES
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)
CjNational Rifle Association
[ |Department of Energy and Environmental Protection (DEEP)
[ Other:
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: [No [_lves Application Status:
FBI Reply: [_]No []Yes ;
CILV LILY LLL ICE Response: [No [Yes [_lApproved [_JDenied
.| Month/Day/Year DMHAS: [No [les
SPBI: [Jno LlvYes (Signature and title of issuing authority)
Number :
DPS-799-C (Rev. 08/04/2022) An Affirmative Action/Equal Employment Opportunity Employer P age 4 of 4

THE NATIONAL RIFLE
ASSOCIATION OF AMIEIRICA
Awards this certificate to
THIS NRA BASIC PISTOL COURSE
CERTIFICATE. IS NO LONGER VALID
OR AUTHORIZED BY THE NRA. IT WAS
DISCONTINUED BY THE NRA IN THE SPRING
OF 2016. for successful completion of the
IF YOU RECEIVED THIS CERTIFICATE, KR A
NRA INSTRUCTOR DID NOT MEET N
PROTOCOL OR THE CONNECTICUBASAT PISTOL
Tipeaw REQUIREMENTS. THE NRA BA
85 Gist. SHOOTING COURSE IS APPROVED
Atl HE STATE OF CONNECTICUT.
Rillg ore INFO, CONTACT: Richard Sheehan
Association | NRA Training Program Specialist
Issued at rsheehan@nrahmor
of America 703-267-1391 omy’. Sey
NRA Certified Instructor,
NRA Certified Instructor, Signature
NRA Secretary
ACA
NRA Certified Instructor, Printed Name
NRA ID #

The information in red
explains how it is entered
on the certificate. The only
item that the instructor
must do to complete this
certificate is to add his/her
Signature
color. It is only available on certificates available to the
instructor when he/she logs in his/her NRA account and
enters the necessary information when the course is
completed. if this logo is not on the certificate, the
information was not forwarded to NRA which makes this
certificate a fake because they may not have followed
NRA protocol or the CT State law.
L,
NATIONAL RIFLE ASSOCIATION OF AMERICA
certifies that
As soon as the instructor submits the report to NRA, the:
NAME of STUDENT
will appear on this certificate and the
instructor can print it for the student.
has successfully completed the
BASICS OF PISTOL SHOOTING
the student's shooting qualification
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
Grsbructors Signature 1234567890 yb ‘ ix
Ri INSTRUCT Dp. number will automatically 7 :
INSTRUCTOR SIGNATURE NSTRUCTOR I.D. wiped cat the cartficate HoaN i FRR picsetiny .
NAME OF INSTRUCTOR January 1, 2035
| NSTRUCTOR PRINTED NAME DATE the course report was submitted to NRA.
will be automatically printed on the certificate SERIAL NUMBER: 123456 a

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
authorities include Federal statutes, State statutcs 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 sccurity 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 reposilories) 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 Blankct 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 hv 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 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 assvciated 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 nuust be advised in writing of the procedures for obtaining a change. correction, or update of your FBI criminal history record as
sct 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 hitps:/Avww.{bi.gov/services/cjis/identity-
history-summary-checks und https:/Avww.cdo.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. Altematively, vou may send your challenge directly to the FBI by
submitting a request via https://www.cdo.cjis.gov. The FBI will then fonvard 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. (Scc 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 establishcd 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) OR
11tt Country Club Road FBI CJS Division-Summary Request
Middlctown, CT 06457 180 Custer Hollow Road
860-685-8180 Clarksburg, West Virginia 26306
SIGNATURE DATE
This document must be retained by the Entity.
1 Written notification includes electronic notification, but excludes oral notification.
? See hitps://www.tbi.gow/services/cjis/compuct-counctV/privacy-act-statement
4 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).