Application For
Includes Your
Personal Tracking Number
FLORIDA
CONCEALED WEAPON
OR FIREARM LICENSE
07/17
You can use the tracking number that appears above to obtain information
concerning the status of your application as it is being reviewed and evaluated by
our Division personnel.
Simply call our ofce at (850) 245-5691 and follow the automated instructions or
check online at www.mylicensesite.com.
• Your tracking number is a UNIQUE ID NUMBER that is linked directly to the
BARCODE that appears on the application on the next page. Therefore,
we ask that you DO NOT MAKE COPIES OF THIS APPLICATION for use by
others. Doing so will make it impossible for you to track the progress of
your own application.
• You should allow 3-4 weeks from the time you mail your application before you
call for a status update.
• Processing time will vary depending upon the Division’s workload. However,
please be advised that if your application is INCOMPLETE or if we receive
background check information from law enforcement authorities that requires
additional review to conrm your eligibility for licensure, processing time may
take up to 90 days.
• Please do not return this page with your application. Keep it in a secure place for
future reference.
YOUR TRACKING NUMBER
PLEASE READ THE FOLLOWING CAREFULLY
Rev. July 2017
T169690606
FDACS-16036 Rev. 07/17
Page 1 of 2
Florida Department of Agriculture and Consumer Services
Division of Licensing
APPLICATION FOR CONCEALED WEAPON OR FIREARM LICENSE
Chapter 790, Florida Statutes
Post Ofce Box 6687sTallahassee, FL 32314-6687s(850) 245-5691
www.mylicensesite.com
S M I T H 1 2 3
SECTION I APPLICANT INFORMATION Read application instructions before you begin. Place letter/number inside each box as shown above.
SOCIAL SECURITY NUMBER ALIEN REGISTRATION NUMBER
LAST NAME FIRST NAME MI
RESIDENCE ADDRESS PHONE NUMBER
RESIDENCE ADDRESS CONTINUED (SUITE, BLDG., APT., ETC.)
CITY STATE ZIP CODE
-
MAILING ADDRESS IF DIFFERENT FROM ABOVE
MAILING ADDRESS CONTINUED (SUITE, BLDG., APT., ETC.)
CITY STATE ZIP CODE
-
SEX RACE EYE COLOR HAIR COLOR DATE OF BIRTH (mmddyyyy) WEIGHT HEIGHT
LBS FT IN
PLACE OF BIRTH - (INCLUDE STATE OR PROVINCE --- AND COUNTRY)
EMAIL ADDRESS
Are you an active-duty United States military servicemember, as dened in Section 250.01, Florida Statutes, or
an honorably discharged United States veteran, as dened in Section 1.01, Florida Statutes, and are requesting
expedited processing of your application?
SECTION II QUALIFYING DATA (SHAdE IN THE APPROPRIATE CIRCLE)
1. Are you applying for this license as a consular security ofcial of a foreign government which meets the
standards dened in Section 790.06(2)(a), Florida Statutes?
2. Do you hold an active certication from the Florida Criminal Justice Standards and Training Commission as a
law enforcement ofcer, correctional ofcer, or correctional probation ofcer as dened in Section 943.10(1),
(2), (3), (6), (7), (8) or (9), Florida Statutes?
3a. Are you a retired Florida law enforcement ofcer, correctional ofcer, or correctional probation ofcer as
dened in Section 943.10 (1), (2) or (3), Florida Statutes?
3b. If you answered YES to Question 3a., have you been retired for one year or less?
VOLUNTARY
See APPLICATION INSTRUCTIONS
If you are an alien, provide your 8- or
9-digit Alien Registration Number.
YES NO
YES NO
YES NO
YES NO
LICCW02
YES NO
WILTON SIMPSON
CO
MMISSIONER
*T169690606*
T169690606
4a. Do you qualify for exemption from the public records law as provided by s. 119.071, Florida Statutes?
4b. If YES, do you wish to have the specied information kept condential?
5a. Have you ever renounced or formally given up United States citizenship?
If YES, you are not eligible for licensure.
5b. Are you currently residing in the United States?
If NO, you are not eligible for licensure unless you are serving overseas in the United States Armed Forces.
5c. Are you a United States citizen? If YES, proceed to question 6. If NO, proceed to question 5d.
5d. Are you deemed a lawful permanent resident alien by the Department of Homeland Security, U.S. Citizenship and
Immigration Services? If you are neither a U.S. citizen nor a permanent resident alien, you are not eligible for
licensure.
6. Have you received training with a rearm as required by Section 790.06(2)(h), Florida Statutes, relating to
competency with a rearm?
7. Have you ever been convicted of a felony?
8. Have you had adjudication of guilt withheld or imposition of sentence suspended on any felony charge?
9. Have you had adjudication of guilt withheld or imposition of sentence suspended on a misdemeanor crime of
domestic violence?
10. Have you been convicted, found guilty of, or had adjudication withheld on one or more misdemeanor crimes of
violence?
11. Have you been convicted or found guilty of a misdemeanor crime of domestic violence?
If YES, you are not eligible for licensure.
12. Have you been issued an injunction that is currently in force and effect that restrains you from committing acts of
domestic violence or acts of repeat violence? If YES, you are not eligible for licensure.
13. Have you ever been adjudicated incapacitated, committed to a mental institution, or adjudicated mentally
defective?
14. During the three years preceding the date of this application, have you been:
a. Committed for the abuse of controlled substances, or been found guilty or convicted of a crime under the
provisions of Chapter 893, Florida Statutes, or similar laws of any other state, or had multiple arrests for such
offenses within the past ve years with the most recent arrest occurring within the past year?
b Committed for the abuse of alcoholic beverages or other substances under the provisions of Chapter 397,
or under the provisions of former Chapter 396, Florida Statutes, or convicted under Section 790.151, Florida
Statutes, or been deemed a habitual offender under the provisions of Section 856.011(3), Florida Statutes, or
similar laws of any other state?
c. Convicted two or more times under Section 316.193, Florida Statutes, or similar laws of any other state for
driving under the inuence of alcohol or a controlled substance?
If you answered YES to any of these questions, you are not eligible for licensure.
15. Are you under arrest or currently charged in any court with a felony, any crime punishable by imprisonment for
more than one year, or any crime of violence, including crimes of domestic violence?
16. Are you a fugitive from justice?
17. Have you been discharged from the Armed Forces under dishonorable conditions?
If YES, you are not eligible for licensure.
SECTION III OATH OF APPLICANT
THIS APPLICATION IS EXECUTED UNDER OATH. FALSIFICATION OR MISREPRESENTATION OF ANY PART OR ANY
DOCUMENT SUBJECTS THE APPLICANT TO CRIMINAL PROSECUTION UNDER SECTION 837.06, FLORIDA STATUTES.
I DO SWEAR AND AFFIRM THAT:
a) I have been provided a website link to Chapter 790, Florida Statutes, relating to weapons and rearms, and that I am knowledgeable of the provisions contained therein.
b) I desire a legal means to carry a concealed weapon or rearm for lawful self-defense.
c) I do not suffer from a physical inrmity that would prevent my safely handling a weapon or rearm.
d) The information contained in this application and all attached documents is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
FDACS-16036 Rev. 07/17
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