STANDARD APPLICATION
for
PERMIT TO CARRY A CONCEALED WEAPON (CCW)

PUBLIC DISCLOSURE ADMONITION

I understand that I am obligated to be complete and truthful in providing information on this application. I understand that all of the information disclosed by me in this application may be subject to public disclosure.

SIGNATURE OF APPLICANT: Dieuson Vert

PRINT NAME OF APPLICANT: Dieuson Vert

DATE (MM/DD/YYYY): 11/20/2016

SECTION 1 - APPLICANT PERSONAL INFORMATION

Firstname and lastname: Dieuson Vert
Date of Birth (MM/DD/YYYY): 11/19/1999
Phone Number: 388993834
Occupation: Civilian

SECTION 2 - REASON FOR PERMIT

If the CCW permit is desired for self-protection, the protection of others, or for the protection of large sums of money or valuable property, you are required to explain and provide good cause for issuance of the permit. For example, has your life or property been threatened or jeopardized? Explain incidents and include dates, times, locations, and names of police agencies to which these incidents were reported.

Details of Reason for Applicant desiring a CCW Permit (100 words): The reason why I wish to be able to have a concealed weapon is for of course self defense. I had an instance where I was in my home cooking and my house was being broken into. At the time I had already made a 911 dispatch but I got no response so my next best chance was to defend myself but I did not have weapon to do so. I would want this permit so that I can defend myself and my family while we are in our homes and not have to worry about anyone threatening my life or my family’s life.


SECTION 3 - CERTIFICATION AND RELEASE OF INFORMATION

I hereby give permission to the agency to which this application is made to conduct a background investigation of me and to contact any person or agency who may add to or aid in this investigation. I further authorize persons, firms, agencies and institutions listed on this application to release or confirm information about me and statements I have made as contained in this application.

I understand that information contained in this application may be a matter of public record and shall be made available upon request or court order.

I hereby declare that I did not copy anything from another application and understand that I will be blacklisted for doing so.

I hereby declare that I have read and understood the "CCW Permit Regulations".

I hereby certify under penalties of perjury that the answers I have given are true and correct to the best of my knowledge and belief, and that I understand and agree to the provisions, conditions, and restrictions herein or otherwise imposed.

Signature of Applicant: Dieuson Vert

Print Name of Applicant: DIEUSON VERT

Date (MM/DD/YYYY): 11/20/2016