Test

[md-form spacing="tight"]
*=required

Your Email *

(Please print full name as it appears on your driver license or state issued ID card)

First Name *

Middle Name *

Last Name *

Physical Address:

Street *

City *

County (i.e. Westechester) *

State *

Zipcode *

Mailing Address (if different from street address)

Mailing Address Street

Mailing Address City

Mailing Address State

Mailing Address Zipcode

Weight (i.e. 180) *

Height (i.e. 5'8") *

Previously used Name(S)(i.e. Maiden, etc.)

Race (White-W, Black-B, Asian-A, American Indian-I, Other/Unknown - U) *
—Please choose an option—WBAIU

Eye Color (Black-BLK, Brown-BRO, Blue-BLU, Gray-GRY, Green-GRN, Hazel-HZL) *
—Please choose an option—BLKBROBLUGRYGRNHZL

Hair Color (Black-BLK, Brown-BRO, Blue-BLU, Gray-GRY, White-WHI, Blonde-BLN, Red-RED, Bald-BLD) *
—Please choose an option—BLKBROBLUGRYWHIBLDBLNRED

Sex *
—Please choose an option—MF

DOB (i.e. 01/16/1975) *

State/Country of Birth *

SSN (i.e. 092-54-6715)

Daytime Phone (i.e. 914-555-1212) *

Alternate Phone (i.e. 914-555-1212)

Driver License Number *

Drivers License State (i.e. NY) *

What is your Citizenship? (i.e. USA) *

If born outside of US, include Alien Registration # or INS Registration #. *

Have you ever been convicted of a felony? *
YesNo

Have you ever been convicted of a crime of violence? *
YesNo

Have you ever been convicted of an offense involving the use of alcohol? (i.e. DUI/DWI, alcohol related reckless, unlawful use of alcohol, etc.) *
YesNo

Have you ever been convicted of the unlawful use of narcotics or other controlled substances *
YesNo

Have you ever been convicted of any offense involving moral turpitude? (i.e., theft, criminal mischief, sex crimes, etc.) *
YesNo

Have you ever been convicted of offense involving domestic violence? *
YesNo

Have you ever been adjudicated as mentally incompetent? *
YesNo

Are you currently subject to a court sanctioned protective order? *
YesNo

Have you ever been dishonorably discharged from the armed forces? *
YesNo

Applicant Name (First and Last Name)

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