CULLMAN COUNTY SHERIFF’S OFFICE
PISTOL PERMIT APPLICATION
STATE OF ALABAMA
Read the following carefully and provide complete and accurate information. It is a crime to make
a false statement or report to law enforcement. (Title 13A-10-109, Code of Alabama).
A criminal history background check will be conducted on each applicant.
Full Name:
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Social Security Number: _______ - _____ - _________ Age: _____ Date of Birth: _____/_____/_____ Sex: Male Female Race: ________
Other Names You Have Been Known By: _________________________________________________________________________________________
County of residence: __________________________________ Requesting permit for ______ years (you may apply for up to five [5] years)
Physical Address: ____________________________________________________________________________________________________________
(Not a P.O. Box) Street Number Apartment Number Street Name City State Zip Code
Mailing Address: ____________________________________________________________________________________________________________
Address City State Zip Code
Email Address: ____________________________________________________________________________________________________________
Phone Numbers: _________________ ___________________ _________________ Place of Birth (City, State): __________________________
Cell Phone Home Phone Work Phone
Are you a U.S. Citizen?
Height: _________ Weight: __________ Hair Color: ________ Eye Color: ________ Yes No
Driver’s License Number: _____________ _________________________ Other State ID: __________ ___________________________________
State License Number State License Number
Yes No Have you ever had a pistol permit ? If yes, where and when ? ______________________________________________________
Yes No Have you ever been convicted of a crime?
Yes No Have you ever had a pistol permit denied or revoked? If so, where and when? _________________________________________
Yes No Are you now or have you ever been under an indictment by
a Grand Jury?
Yes
No Are
you
now or have you ever been treated for a mental illness or substance abuse (drugs/alcohol) ?
Yes No Are you now or have you ever been under a restraining order or protection order to prevent endangering yourself or others?
Yes No Are you awaiting trial as a defendant in any criminal case?
Yes No Have you been found guilty by reason of mental illness in a criminal case?
Yes No Have you been found not guilty in a criminal case by reasons of insanity or mental disease or defect?
Yes No Have you been declared incompetent to stand trial in a criminal case?
Yes No Have you asserted a defense in a criminal case of not guilty by reason of insanity or mental disease or defect?
Yes No Have you been found not guilty by reason of lack of mental responsibility under the Uniform Code of Military Justice?
Yes No Have you required involuntary outpatient treatment in a psychiatric hospital or similar treatment facility based on a finding that you are an
imminent danger to yourself or to others?
Yes No Have you required involuntary commitment to a psychiatric hospital or similar treatment facility for any reasons, including drug use?
Yes No Have you been the subject of a prosecution or of a commitment or incompetency proceeding that could lead to a prohibition on the receipt
or possession of a firearm under the laws of Alabama or the United States?
If you answered YES to any of the questions above, please use the space below to provide dates and places of arrests or treatment, charges, agency involved and dispositions.
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I certify that my answers are true, complete and correct and I understand this application will be rejected if any information if found to be false or misleading.
Applicant’s Signature: ________________________________________________________________ Date: _____________________________________
DO NOT WRITE BELOW THIS LINE – FOR OFFICIAL USE ONLY
APPROVED:_______ (INITIAL)
YES// NO
RECORD FOUND? YES// NO
NEED DISPOSITION?
RECORD CHECKED BY: _______________ (INITIAL)
NCIC: ACJIC:
NICS:
AUTHORIZED SIGNATURE: _____________________________________________ DATE APPROVED/DENIED: _____________________
(PLEASE PUT A CHECK BESIDE YOUR ANSWER)
DENIED: _______ (INITIAL)
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