Polk County Sheriff's Office 850 Main Street Dallas, Oregon 97338-3185 (503) 623-9251 Fax (503) 623-2060
Sheriff Bob Wolfe
Criminal Division
Jail Division
Civil Division
Marine Patrol Division
Emergency Management
APPLICATION FOR LICENSE TO CARRY CONCEALED HANDGUN
(This application must be legible or it will not be accepted)
Date
I hereby declare as follows:
(Print full Legal Name)
I am a citizen of the United States or a legal resident alien who can document continuous
residency in the county for at least six months and have declared in writing to the Immigration
and Naturalization Service my intention to become a citizen and can present proof of the
written declaration to the sheriff at the time of this application. I am at least 21 years of age.
I have been discharged from the jurisdiction of the juvenile court for more than four years if,
while a minor I was found to be within the jurisdiction of the juvenile court for having committed
an act which, if committed by an adult, would constitute a felony or a misdemeanor involving
violence, as defined in ORS 166.470. I have never been convicted of a felony or found guilty,
except for insanity under ORS 161.295, of a felony in the State of Oregon or elsewhere. I have
not within the last four years, been convicted of a misdemeanor or found guilty, except for
insanity under ORS 161.295, of a misdemeanor. There are no outstanding warrants for my
arrest and I am not free on any form of pretrial release. I have not been committed to the
Mental Health and Developmental Disability Services Division under ORS 426.130, nor have
I been found mentally ill and presently subject to an order prohibiting me from purchasing or
possessing a firearm because of mental illness. If any of the previous conditions do apply to
me, I have been granted relief or wish to petition for relief from the disability under ORS
166.274 or 166.293 or 18 U.S.C. 925© or have had the records expunged. I am not subject to
a citation issued under ORS 163.735 or an order issued under ORS 30.866, 107.700 to
107.732 or 163.738. I understand I will be fingerprinted and photographed.
__________
(Signature of Applicant)
Age: Date of Birth: Place of Birth: Citizenship: (country)
Social Security Number (Disclosure of your social security account number is
voluntary. Solicitation of the number is authorized under ORS 166.291. It will be used only as
a means of notification.)
Height: Weight: Hair: Eyes: Sex : Race:
Current Address: City:
County: Zip: Telephone: Message:
How long have you resided at this present address? (years) (months)
(List residence address for past three years)
Previous Addresses
Place of Employment Telephone
Address
If self-employed state type of business:
REFERENCES
1 ___________________
Name Address
____________________
City State Zip Code Telephone
2. ___________________
Name Address
____________________
City State Zip Code Telephone
3. ____________________
Name Address
____________________
City State Zip Code Telephone
I have read the entire text of this application and the statements therein are correct and true. Making false statements on this application is a misdemeanor.
_______
(Signature of Applicant)
"SPACE BELOW FOR OFFICIAL USE ONLY"
Approved Disapproved By
Competence with handgun demonstrated by: (CHL) (NRA CERTIFICATE) (OTHER) _________________
Additional Comments:
Proof of identification (Two pieces of current identification are required, one of which must bear a photograph of the applicant. Type of identification and number of identification to be filled in by the Sheriff's Office):
(Type): Number Expiration Date:
(Type): Number Expiration Date: _