RETIREE CONCEALED WEAPON PERMIT APPLICATION …
[Pages:1]MSHP
MISSOURI STATE HIGHWAY PATROL
SHP-133 10/04
RETIREE CONCEALED WEAPON PERMIT APPLICATION
Retired Law Enforcement Officer Safety Act Request
APPLICANT'S NAME (Last, First, MI)
DATE OF BIRTH
ID NUMBER (Issued by Patrol Range Officer)
APPLICANT'S ADDRESS (Street, City, State, Zip)
TELEPHONE
The Law Enforcement Officer Safety Act of 2004 defines persons who are eligible to carry a concealed weapon. The following statements are included in this definition. Please read and initial each statement below to affirm that you meet the stated requirement.
1. I am retired in good standing (other than reasons of mental instability).
2. Prior to retirement, I had statutory powers of arrest. 3. I was regularly employed as a certified peace officer for 15 years or more; or I retired with a
service-connected disability after completing any probationary period. 4. I have a nonforfeitable right to benefits under the agency's retirement plan.
5. I am not under the influence of alcohol or another intoxicating / hallucinatory drug or substance.
6. I am not prohibited by federal law from receiving a firearm.
I hereby acknowledge that I meet the aforesaid criteria as a retired uniformed member of the Missouri State
Highway Patrol.
APPLICANT'S SIGNATURE
DATE
TIME
In addition to the federal mandated criteria, the applicant named above has submitted to a Purpose Code F
Background Check and was found to be free of any prohibitions of possessing a concealable firearm in the
State of Missouri.
RADIO OPERATOR PERFORMING CHECK
PRINT NAME (First MI Last)
BADGE SIGNATURE
DATE
TIME
APPLICANTS ARE ALLOWED TO QUALIFY WITH ONLY ONE FIREARM
WEAPON - CALIBER
MODEL
MANUFACTURER
SERIAL NUMBER
Section below completed by MSHP range officer
QUALIFICATION DATE
Applicant Has Successfully Completed Firearms Training
RANGE OFFICER'S VERIFICATION / COMMENTS
RANGE OFFICER
PRINT NAME (First MI Last)
ROUTING: ORIGINAL - Filed in Troop/Division.
BADGE SIGNATURE COPY - Forward to Administrative Services Bureau
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