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Last (If female, include maiden.), First, Middle
Number and Street, City, State, Zip
City, State, County
(Marks, Scars, Tattoos)
I hereby certify that the answers given on this application are complete, true and correct in every particular. I realize that if any of the foregoing answers made by me are false, I am subject to punishment.
(The disclosure of my social security number is voluntary. Without this number, the processing of my application may be delayed. This number is considered confidential.)
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
This consent must be completed by the firearm applicant. Failure to consent requires denial or disapproval of the application.
N.J.S.A. 30:4-24.3 provides that all records of any individual's commitment to a non-correctional institution for mental health reasons shall be confidential and shall not be disclosed except in limited circumstances or with the consent of the individual.
Last, Maiden, First, Middle
(See privacy act notice below.)
Number and Street
Applicant's Social Security Number is requested pursuant to N.J.S.A. 2C:58-3(e) and disclosure is voluntary. The number will be used to expedite the application. Without this number, the processing of the application may be delayed. This number is considered confidential.
I am aware of my rights under N.J.S.A. 30:4-24.3, and the Health Insurance Portability and Insurance Accountability Act (HIPAA), 45 C.F.R. 164-50, and consent of the disclosure of my mental health records, included disclosure of the fact that said records may have been expunged, to the Chief of Police and the Superintendent of State Police, or their designees, for the purpose of verifying my firearms permit application and my fitness to own a firearm under N.J.S.A. 2C:58-3. I understand that copies of this authorization shall be considered sufficient authorization for the release of records or for the disclosure of the fact of expungement.
(Doctor provide medical license number)
A photostatic copy of this authorization will be considered as effective and valid as the original.
This field is not part of the form submission.
* indicates a required field