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2. It is necessary that we conduct an investigation to ensure that only the applications of persons qualified by law are approved.  Your cooperation in truthfully answering and completing this questionnaire is necessary to help us make this determination.

6. As the person completing this reference questionnaire, please provide YOUR information in this section.

   DO NOT ENTER THE APPLICANT NAME IN THIS SECTION.

8. Your Full Name*
9. Your E-Mail Address*
10. Your Phone Number*
12. Your Address:*
13. Your City*
14. Your State*
15. Your Zip Code*

19. Please provide information about the APPLICANT in this section.

    DO NOT ENTER YOUR NAME IN THE APPLICANT NAME FIELD.

21. Applicant's Full Name*
23. To your knowledge, has the applicant ever been convicted of a crime or disorderly person’s offense?*

    1. Yes
    2. No
25. If YES, please explain.
27. To your knowledge, is the applicant an alcoholic or currently a habitual drunkard?*

    1. Yes
    2. No
29. If YES, please explain.
31. To your knowledge, does the applicant use illegal narcotics or is the applicant addicted to prescription medication?*

    1. Yes
    2. No
33. If YES, please explain.
35. To your knowledge, does the applicant suffer from any physical defect or illness which would make it unsafe to handle firearms?*

    1. Yes
    2. No
37. If YES, please explain.
39. To your knowledge, has the applicant ever been confined to a mental institution or been treated for a mental defect?*

    1. Yes
    2. No
41. If YES, please explain.
43. To your knowledge, does the applicant suffer from any mental condition which would make it unsafe to handle firearms?*

    1. Yes
    2. No
45. If YES, please explain.
47. To your knowledge, has the applicant ever been involved in a Domestic incident?*

    1. Yes
    2. No
49. If YES, please explain.
51. To your knowledge, has the applicant ever been a member of any organization which advocates the overthrow of the U.S. Government or the State of New Jersey?*

    1. Yes
    2. No
53. If YES, please explain.
55. How many years have you known the applicant?*
57. Is there any reason you would NOT endorse the above named applicant to be issued a concealed carry permit for a handgun?*

    1. Yes
    2. No
59. If YES, please explain.
61. I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this reference void. Furthermore, I affirm that I am indeed the named individual listed above and that I am submitting this reference on my own behalf.*

    1. I agree.
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field