APPLICATION FOR A PENNSYLVANIA LICENSE TO CARRY

SP 4-127 (7-2024) COMMONWEALTH OF PENNSYLVANIA

RENEWAL

COUNTY OF______________________________

APPLICATION FOR A PENNSYLVANIA LICENSE TO CARRY FIREARMS

FOR USE BY ISSUING AUTHORITY: PICS Temp App. No _____________ PICS Perm. App. No. ______________ Application Date _____________

License No. _________________ Temporary License Approval Date __________________ Permanent License Approval Date ___________________

Rejection Date ____________ Reason for Rejection _________________________________ Signature ____________________________________

APPLICANT INFORMATION – TYPE/PRINT IN BLUE OR BLACK INK

1. LAST NAME

2. JR., ETC.

3. FIRST NAME

4. MIDDLE NAME

5. PHOTO ID/DRIVER LICENSE NO.

6. STATE

7a. DATE OF BIRTH

7b. PLACE OF BIRTH

8. SOCIAL SECURITY NUMBER

(Optional)

9. AGE

10. SEX

11. RACE

12. HEIGHT

13. WEIGHT

14. HAIR COLOR

15. EYE COLOR

16. STREET ADDRESS

17. CITY

18. STATE

19. ZIP CODE

20. TELEPHONE NO.

21. PERSONAL EMAIL (Blocks 21-23 Optional)

22. EMPLOYER/BUSINESS NAME

23. WORK TELEPHONE NO.

24. REASON FOR A LICENSE TO CARRY FIREARMS:

SELF-DEFENSE EMPLOYMENT HUNTING/FISHING TARGET SHOOTING GUN COLLECTING OTHER

___________________________

25. TWO REFERENCES (Optional) NOT FAMILY MEMBERS

NAME

ADDRESS

TELEPHONE NO.

NAME

ADDRESS

TELEPHONE NO.

APPLICANTS ARE DETERMINED TO BE ELIGIBLE FOR A LICENSE TO CARRY FIREARMS BASED UPON CRITERIA LISTED IN 18 Pa.C.S. § 6109.

26. DO ANY OF THESE PROHIBITING CRITERIA UNDER 18 PA.C.S. § 6109(e)(1) APPLY TO YOU? CHECK YES OR NO:

A. IS YOUR CHARACTER AND REPUTATION SUCH THAT YOU WOULD BE LIKELY TO ACT IN A MANNER DANGEROUS TO PUBLIC

SAFETY?

YES NO

B. HAVE YOU EVER BEEN CONVICTED OF AN OFFENSE UNDER THE PENNSYLVANIA CONTROLLED SUBSTANCE, DRUG, DEVICE

AND COSMETIC ACT (CSDDCA)? (ANY PENNSYLVANIA DRUG CONVICTION UNDER THE CSDDCA IS PROHIBITING FOR A

LICENSE TO CARRY.)

YES NO

C. HAVE YOU EVER BEEN CONVICTED OF A CRIME LISTED IN 18 PA.C.S. § 6105(b), OR DO ANY OF THE CONDITIONS LISTED IN

18 PA.C.S. § 6105(c) APPLY TO YOU? (READ INFORMATION ON BACK PRIOR TO ANSWERING)

YES NO

D. HAVE YOU EVER BEEN ADJUDICATED DELINQUENT FOR A CRIME LISTED IN 18 PA.C.S. § 6105 OR FOR AN OFFENSE UNDER

THE CONTROLLED SUBSTANCE, DRUG, DEVICE AND COSMETIC ACT?

YES NO

E. HAVE YOU EVER BEEN INVOLUNTARILY COMMITTED TO A HOSPITAL/HEALTH CARE FACILITY FOR A MENTAL HEALTH

CONDITION OR OTHER TREATMENT, OR ADJUDICATED INCOMPETENT/INCAPACITATED?

YOU MAY CHECK “NO” IF YOU HAVE

BEEN GRANTED RELIEF OR EXPUNGEMENT IN PENNSYLVANIA PURSUANT TO EITHER 18 PA.C.S. 6105(F)(1) OR 6111.1(G)(2), OR BY

THE ADJUDICATING/COMMITTING STATE PURSUANT TO A QUALIFYING MENTAL HEALTH RELIEF FROM DISABILITIES PROGRAM, AS

SET FORTH IN 34 U.S.C. § 40915.

YES NO

F. ARE YOU AN INDIVIDUAL WHO IS A HABITUAL DRUNKARD, OR WHO IS ADDICTED TO OR AN UNLAWFUL USER OF MARIJUANA

OR A STIMULANT, DEPRESSANT, OR NARCOTIC DRUG?

YES NO

G. ARE YOU NOW CHARGED WITH, OR HAVE YOU EVER BEEN CONVICTED OF A CRIME PUNISHABLE BY IMPRISONMENT FOR A

TERM EXCEEDING ONE YEAR? THIS IS THE MAXIMUM SENTENCE YOU COULD HAVE RECEIVED, NOT THE ACTUAL

SENTENCE YOU DID RECEIVE. (IT DOES NOT INCLUDE FEDERAL OR STATE OFFENSES PERTAINING TO ANTITRUST, UNFAIR

TRADE PRACTICES, RESTRAINTS OF TRADE, OR REGULATION OF BUSINESS; OR STATE OFFENSES CLASSIFIED AS

MISDEMEANORS AND PUNISHABLE BY A TERM OF IMPRISONMENT NOT EXCEEDING TWO YEARS.)

YES NO

H. HAVE YOU EVER RECEIVED A DISHONORABLE DISCHARGE FROM THE UNITED STATES ARMED FORCES?

YES NO

I. ARE YOU A FUGITIVE FROM JUSTICE? THIS DOES NOT APPLY TO MOVING OR NONMOVING SUMMARY OFFENSES UNDER

TITLE 75 (RELATING TO MOTOR VEHICLES), BUT DOES INCLUDE OUTSTANDING ARREST AND BENCH WARRANTS.

YES NO

J. ARE YOU PROHIBITED FROM POSSESSING OR ACQUIRING A FIREARM UNDER THE STATUTES OF THE UNITED STATES?

YES NO

27. ARE YOU A UNITED STATES CITIZEN? IF NO, COUNTRY OF BIRTH___________________________________________

COUNTRY OF CITIZENSHIP____________________________________ ALIEN REGISTRATION # OR I-94#______________________________

YES NO

28. IF YOU ARE A RESIDENT OF ANOTHER STATE, DO YOU POSSESS A CURRENT LICENSE, PERMIT, OR SIMILAR DOCUMENT TO CARRY A

FIREARM ISSUED BY THAT STATE? IF YES, ATTACH A PHOTOCOPY OF THE DOCUMENT TO THIS FORM.

YES NO

29. ARE YOU CURRENTLY ON ANY TYPE OF PROBATION/PAROLE WHICH PROHIBTS THE POSSESSION OR CONTROL OF A FIREARM?

YES NO

30. I have never been convicted of a crime that prohibits me from possessing or acquiring a firearm under Federal or State law. I am of sound mind and have

never been committed to a mental institution or mental health care facility. I hereby certify that the statements contained herein are true and correct to the

best of my knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties prescribed by law. I authorize

the sheriff, or his designee, or, in the case of first-class cities, the chief or head of the police department, or his designee, to inspect only those records or

documents relevant to information required for this application. If I am issued a license and knowingly become ineligible to legally possess or acquire

firearms, I will promptly notify the sheriff of the county in which I reside or, if I reside in a city of the first class, the chief of police of that city.

This certification is made subject to both the penalties of 18

Pa.C.S. § 4904, relating to unsworn falsifications to authorities and the Uniform Firearms Act.

SIGNATURE - APPLICANT _____________________________________________________ DATE OF APPLICATION _________________________

18 Pa.C.S. Section 6105(a)(1): A person who has been convicted of an offense enumerated in subsection (b), within or without this Commonwealth,

or whose conduct meets the criteria in subsection (c) shall not possess, use, control, sell, transfer or manufacture or obtain a license to possess,

use, control, sell, transfer, or manufacture a firearm in this Commonwealth.

Section 6105(a.1)(2): A person who is the subject of an active final protection from abuse order issued pursuant to 23 Pa.C.S. § 6108, is the subject

of any other active protection from abuse order issued pursuant to 23 Pa.C.S. § 6107(b) (relating to hearings), which provided for the relinquishment

of firearms or other weapons or ammunition during the period of time the order is in effect, or is otherwise prohibited from possessing or acquiring

a firearm under 18 U.S.C. § 922(g)(8) (relating to unlawful acts), commits a misdemeanor of the second degree if he intentionally or knowingly fails

to relinquish a firearm or other weapon or ammunition.

Section 6105(b)

§908 Prohibited offensive weapons

§911 Corrupt organizations

§912 Possession of weapon on school property

§2502 Murder

§2503 Voluntary manslaughter

§2504 Involuntary manslaughter, if the offense is based on t

reckless use of a firearm

§2702 Aggravated assault

§2703 Assault by prisoner

§2704 Assault by life prisoner

§2709.1 Stalking

§2716 Weapons of mass destruction

§2901 Kidnapping

§2902 Unlawful restraint

§2910 Luring a child into a motor vehicle or structure

§3121 Rape

§3123 Involuntary deviate sexual intercourse

§3125 Aggravated indecent assault

§3301 Arson and related offenses

§3302 Causing or risking catastrophe

§3502 Burglary

§3503 Criminal trespass, if the offense is graded a felony of the

second degree or higher

§3701 Robbery

§3702 Robbery of motor vehicle

§3921 Theft by unlawful taking or disposition, upon conviction of the

second felony offense

§3923 Theft by extortion, when the offense is accompanied by

threats of violence

§3925 Receiving stolen property, upon conviction of the secon

felony offense

§4906 False reports to law enforcement authorities, if the fictitious

report involved the theft of a firearm as provided in 4906(c)(2)

§4912 Impersonating a public servant if the person is impersonatin

a law enforcement officer

§4952 Intimidation of witnesses or victims

§4953 Retaliation against witness, victim or party

§5121 Escape

§5122 Weapons or implements for escape

§5501(3) Riot

§5515 Prohibiting of paramilitary training

§5516 Facsimile weapons of mass destruction

§6110.1 Possession of firearm by minor

§6301 Corruption of minors

§6302 Sale or lease of weapons and explosives

Any offense equivalent to any of the above-enumerated offenses

under the prior laws of this Commonwealth, or any offense equivalent

to any of the above-enumerated offenses under the statutes of any

other state or of the United States.

Section 6105(c):

18 Pa.C.S. § 6105(c) also prohibits the following persons from possessing, using, controlling, transferring, manufacturing, or obtaining a license to

possess, use, control, transfer, or manufacture a firearm in the Commonwealth of Pennsylvania.

ARE YOU A PERSON WHO:

1. is a fugitive from justice; or

2. has been convicted of an offense under the Pennsylvania Controlled Substance, Drug, Device and Cosmetic Act, or any equivalent Federal

statute or equivalent statute of any other state, that may be punishable by a term of imprisonment exceeding two years; or

3. has been convicted of driving under the influence of alcohol or controlled substance as provided in 75 Pa.C.S. § 3802 (relating to driving under

the influence of alcohol or controlled substance) or the former 75 Pa.C.S. § 3731, on three or more separate occasions within a five-year

period. For the purposes of this paragraph only, the prohibition of Section 6105(a) shall only apply to transfers or purchases of firearms after

the third conviction; or

4. has been adjudicated as an incompetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under

section 302, 303, or 304 of the Pennsylvania Mental Health Procedures Act; or

5. being an alien, is illegally or unlawfully in the United States; or

6. is the subject of an active final protection from abuse order issued pursuant to 23 Pa.C.S. § 6108, is the subject of any other active protection

rom abuse order issued pursuant to 23 Pa.C.S. § 6107(b), which provided for the relinquishment of firearms during the period of time the order

is in effect or is otherwise prohibited from possessing or acquiring a firearm under 18 U.S.C. § 922(g)(8). This prohibition shall terminate upon

the expiration or vacation of the order or portion thereof relating to the relinquishment of firearms; or

7. was adjudicated delinquent by a court pursuant to 42 Pa.C.S. § 6341 (relating to adjudication) or under any equivalent Federal statute or statute

of any other state as a result of conduct which if committed by an adult would constitute an offense under 18 Pa.C.S. sections 2502, 2503,

2702, 2703, 2704, 2901, 3121, 3123, 3301, 3502, 3701, and 3923; or

8. was adjudicated delinquent by a court pursuant to 42 Pa.C.S. § 6341 or under any equivalent Federal statute or statute of any other state as a

result of conduct which if committed by an adult would constitute an offense enumerated in 18 Pa.C.S. § 6105(b) with the exception of those

crimes set forth in paragraph 7. This prohibition ends 15 years after the delinquency adjudication or upon the person reaching the age of 30,

whichever is earlier.

9. is prohibited from possessing or acquiring a firearm under 18 U.S.C. § 922(g)(9) (Misdemeanor Crime of Domestic Violence). 18 U.S.C. §

921(a)(33) generally states that the term “misdemeanor crime of domestic violence” means an offense that— (i) is a misdemeanor under

Federal, State, Tribal, or local law; and (ii) has, as an element, the use or attempted use of physical force, or the threatened use of a deadl

weapon, committed by a current or former spouse, parent, or guardian of the victim, by a person with whom the victim shares a child in common,

by a person who is cohabiting with or has cohabited with the victim as a spouse, parent, or guardian, by a person similarly situated to a spouse,

parent, or guardian of the victim, or by a person who has a current or recent former dating relationship with the victim.

10. has been convicted of an offense under subsection (a.1)(2). The prohibition shall terminate five years after the date of conviction, final release

from confinement or final release from supervision, whichever is later.

PRIVACY ACT NOTICE

Solicitation of this information is authorized under Title 18 Pa.C.S. § 6111. Disclosure of your social security number is voluntary. Your social security

number, if provided, may be used to verify your identity and prevent misidentification. All information supplied, including your social security number, is

confidential and not subject to public disclosure.