Shelby County Sheriff's Office - Pistol Permit Application

Inmate Listing

Dispatch Log

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Last Name: First Name: Middle Name:

Mailing Address: City: Zip:

Street Address: City: Zip:

Home Telephone:

Place of Birth: United States Citizen? Yes No

Employer: Address:

Work Phone: Occupation:

Race: Ethnicity:
Sex: Date of Birth: Driver License #:

Social Security #: Height: Weight:

Hair Color: Eye Color:
Marital Status:

Scars, Marks, Tattoos:

3 References REQUIRED (DO NOT LIST RELATIVES)

Reference #1:Name Telephone

Reference #2:Name Telephone

Reference #3:Name Telephone

Reason for carrying a pistol:

Have you ever had a permit refused or revoked? Yes
Date: Location: Charge:

Have you ever been arrested?
Yes No
If Yes, list date, charge, and disposition of each arrest:

Have you ever been adjudicated mentally defective (which includes having been adjudicated incompetent to manage your own affairs) or have you ever been committed to a mental institution?
Yes No

Any other names you have been known by:

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