Malheur Countychl Application
Malheur Countychl Application
Malheur Countychl Application
(541) 473-5126
(541) 473-5126
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First
Full Middle
Last
_______________________________________
__________________________________________
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City
State
Zip
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City
State
Zip
All applicants must provide proof of citizenship. A US Birth Certificate, US Passport, FFS240 (Military Service
Foreign Birth Form) or Naturalization paperwork will work for proof of citizenship. If you are a legal resident alien who
can document continuous residency in Malheur County for at least 6 months, and have declared in writing to the
Immigration and Naturalization Service of your intent to become a citizen and can provide our office proof of receipt (the
N-300 or N-400 form) this will be accepted as your citizenship requirement.
List other states you have resided in as an adult (18 years or older):
______________________________________________________________________________________
List residence addresses for the past three years:
______________________________________________________________________________________
(NEW APPLICANTS ONLY)
Please list two character references who are not related to you and who do not reside at your residence:
1. Name and complete mailing address:
______________________________________________________________________________________
2. Name and complete mailing address:
______________________________________________________________________________________
Initial each line indicating that you have read each statement. Please read Carefully!
I HEREBY DECLARE AS FOLLOWS:
_____ I am a citizen of the United States. If I am not a citizen, I am a legal resident alien who can
document continuous residency in Malheur County, or a bordering state, for at least six
months and have declared in writing to the Citizenship and Immigration Services 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 now at least 21 years of age.
_____ I have NOT been under the jurisdiction of the juvenile department for the last four years for
committing an act, that if committed by an adult, would constitute a felony or a
misdemeanor involving violence.
_____ I have NEVER been convicted or found guilty of a felony in the State of Oregon or
elsewhere.
_____ I have NOT been convicted of a misdemeanor or found guilty of a misdemeanor in the State
of Oregon or elsewhere in the last four years.
_____ There are no outstanding warrants for my arrest.
_____ I do not have any charges pending in any court resulting from a citation or arrest.
_____ I have not been mentally committed by a court nor have I been found mentally ill and
presently subject to an order prohibiting me from purchasing a firearm because of mental
illness.
_____ I am not subject to a citation or court order restraining me from contacting or stalking
another.
_____ I have not received a dishonorable discharge (enlisted members) or received a dismissal
(commissioned officers) from the U.S. Armed Forces.
_____ I am not required to register as a sex offender in any state.
_____ I understand that I will be photographed and if I am a new applicant I will be fingerprinted.
Privacy Questions:
(___) Yes (___) No I am requesting that my application and information be maintained as
confidential and not be released to the public.
(___) Yes (___) No I am applying for a Concealed Handgun License as a personal safety
measure; I do not want any information about my application of CHL status released to the
public.
I have read the entire text of this application and understand it completely. All information I have
submitted on this application is correct and true. I understand placing false information or making
false statements on this application is a crime. If I have made false statements I am subject to
prosecution and my application will automatically be denied or revoked.
Signature: ______________________________________________________ Date: ________________________
Print Name: ____________________________________________________