(19) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, or permit to carry a handgun refused or revoked? If Yes, By Whom?
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(19) Have you ever had a firearms purchaser identification card, permit to purchase a handgun, or permit to carry a handgun refused or revoked? If Yes, By Whom?
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or outpatient location of NOTICE: If Internet form, print Page 1, return to printer and print Page 2 on reverse side.
STATE OF NEW JERSEY
Application for Permit to Carry a Handgun
Application must be delivered, in triplicate, to the Chief of Police of the municipality wherein you reside, or to the
Superintendent of State Police in all other cases. A money order in the amount of $50.00 payable to the State of New
Jersey - Treasurer must accompany this application.Answer all questions. If more space is needed, attach bond paper. Page two must be completed. Four photographs of the applicant, one and one-half inch square,
head and shoulders, no hat, light background, taken within the last 30 days must accompany this application.
NEW RENEWAL
Municipal CodeThis form is prescribed by the Superintendent for use by applicants for a Permit to Carry a Handgun. Any alteration to this form is expressly forbidden.(12) Telephone (13) Email
Reason for Disapproval
A. CRIMINAL RECORD
B. PUBLIC HEALTH, SAFETY, AND WELFARE
C. MEDICAL, MENTAL, OR ALCOHOLIC BACKGROUND
D. NARCOTICS/DANGEROUS DRUG OFFENSE
E. FALSIFICATION OF APPLICATION
F. DOMESTIC VIOLENCE
G. OTHER (Specify) _____________________________
S.P. 642 (Rev. 07/22)
No. Street Address
City/Town State Zip
Home Telephone Number Business Telephone NumberPrint or Type NameSignature
Date of Endorsement
Endorsement Number One - Reference must have known applicant for a minimum of three years preceding the date of the application.S.P. 642 (Rev. 0) Page 2
Photograph of
Applicant
1.5 x 1.5 inches
SPACE BELOW RESERVED FOR SUPERIOR COURT JUDGE GRANTING PERMITList Permit Restrictions Here:
State of New Jersey
County of
being duly sworn, upon oath deposes and states that he/she is the applicant named on page oneof this application; that the answers to the questions given on this application are complete, true and correct in every particular.
This Day of , 20Notary Public
SSName of Applicant from page one
Signature of Applicant named on page one Date of Application (The disclosure of my social security number is voluntary. Without this number, the processing of my application may be delayed. This number is considered confidential.) I realize that if any of the foregoing answers made by me are false, I am subject to punishment. Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c.Endorsement Number Two Reference must have known applicant for a minimum of three years preceding the date of the application.
I am personally acquainted with , the applicant named on page one of this application. I have known Him/Her for
the past years to be a person of good moral character and behavior and who is capable of exercising self control. I have reviewed this application
and I believe that the answers given by the applicant to the questions set forth in this application are complete, true and correct in every particular.
Name of applicant from page one
No. Street Address
City/Town State Zip
Home Telephone Number Business Telephone NumberPrint or Type NameSignature
Date of Endorsement
Endorsement Number Three - Reference must have known applicant for a minimum of three years preceding the date of the application.
I am personally acquainted with , the applicant named on page one of this application. I have known Him/Her for
the past years to be a person of good moral character and behavior and who is capable of exercising self control. I have reviewed this application
and I believe that the answers given by the applicant to the questions set forth in this application are complete, true and correct in every particular.
Name of applicant from page one
No. Street Address
City/Town State Zip
Home Telephone Number Business Telephone NumberPrint or Type NameSignature
Date of Endorsement
I am personally acquainted with , the applicant named on page one of this application. I have known Him/Her for
the past years to be a person of good moral character and behavior and who is capable of exercising self control. I have reviewed this application
and I believe that the answers given by the applicant to the questions set forth in this application are complete, true and correct in every particular.