Jefferson County Sheriff's Office

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Sign printed form where stated.

This form must be submitted in person at our offices in Birmingham, Bessemer, or Centerpoint.

Last Name: First Name: Middle Name:

Home Address: City: Zip:

Home Telephone: Email Address

Place of Birth:

Employer: Address:

Work Phone: Occupation:

Race: Sex: Date of Birth: Driver License #: Age(Must be 21)

Social Security #: Height: Weight:

Hair Color: Eye Color:

3 References REQUIRED (DO NOT LIST RELATIVES, References must sign)

Reference #1:Name Telephone Address

Reference #2:Name Telephone Address

Reference #3:Name Telephone Address

Report of identification officer: If record, list below.

If no record, check none None

Reason for carrying a pistol:

Do you work where alcoholic beverages are sold?

How long have you lived in Jefferson County?

Have you ever been arrested for any crime offense, including misdemeanors and traffic violations?
Yes No
If Yes, list all traffic violations and crimes for which you were charged

I hereby affirm that all of the answers in the foregoing application are true. I further affirm that I have never been known by any other name than

Remarks: