1
FORM
PART A PENDING CHARGES
(
,
)
FOR ADDITIONAL PENDING CHARGES
USE A PIECE OF PLAIN PAPER AND ATTACH
:
________________________________________________________
DESCRIBE THE PENDING CRIMINAL CHARGE AGAINST YOU
: ___________________
,
: _____________________________________
DATE OF CHARGE
COUNTY
CITY AND STATE OF CHARGE
:
___________________________________________________________________________
CURRENT STATUS OF CHARGE
PART B CONVICTIONS
(
,
)
FOR ADDITIONAL CONVICTIONS
USE A PIECE OF PLAIN PAPER AND ATTACH
:
_______________________________________________________
DESCRIBE THE CHARGE FOR WHICH YOU WERE CONVICTED
:___________________
,
: __________________________________
DATE OF CONVICTION
COUNTY
CITY AND STATE OF CHARGE
?
HAVE YOU RECEIVED A PARDON OR RESTORATION OF RIGHTS THAT INCLUDES YOUR FIREARM RIGHTS
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
/
HAVE YOU BEEN CONVICTED
ADJUDICATED OF AN OFFENSE AS A JUVENILE WHICH WOULD HAVE BEEN A FELONY IF
YES
NO
?
COMMITTED BY AN ADULT
,
IF YES
HAVE YOU COMPLETED A TERM OF SERVICE OF NO LESS THAN TWO YEARS IN THE ARMED FORCES OF THE UNITED
YES
NO
?
.
STATES
ATTACH SUPPORTING DOCUMENTATION
DID YOU RECEIVE AN HONORABLE DISCHARGE
YES
NO
NOT APPLICABLE
2
FORM
PART A COMMITMENTS TO THE COMMISSIONER OF HEALTH AND DEVELOPMENTAL SERVICES
:_______________
:__________________________________
DATE OF COMMITMENT
DATE YOU WERE RELEASED FROM CUSTODY
: _____________________________________________________________________
NAME OF COURT WHICH ENTERED THE ORDER
(
,
,
,
)_______________________________________________
LOCATION OF COURT
INCLUDE STREET ADDRESS
CITY
COUNTY
AND STATE
?
HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT
YES
NO
,
?
IF YES
HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
PART B ADJUDICATION OF LEGAL INCOMPETENCE OR MENTAL INCAPACITATION
:________________
:_______________________________
DATE OF ADJUDICATION
NAME OF COURT WHICH ENTERED THE ORDER
(
,
,
,
)_______________________________________________
LOCATION OF COURT
INCLUDE STREET ADDRESS
CITY
COUNTY
AND STATE
?
HAS YOUR COMPETENCY OR CAPACITY HAS BEEN RESTORED BY A COURT
YES
NO
,
?
IF YES
HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
PART C
INVOLUNTARY ADMISSIONS
: ________________________
:____________________
DATE INVOLUNTARILY ADMITTED
DATE RELEASED FROM THIS ADMISSION
: _____________________________________________________________________
NAME OF COURT WHICH ENTERED THE ORDER
(
,
,
,
) _______________________________________________
LOCATION OF COURT
INCLUDE STREET ADDRESS
CITY
COUNTY
AND STATE
?
HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT
YES
NO
,
?
IF YES
HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
PART D MANDATORY OUTPATIENT TREATMENT
:
____________________________________________________
DATE ORDERED TO MANDATORY OUTPATIENT TREATMENT
:
____________________________________________________
DATE RELEASED FROM MANDATORY OUTPATIENT TREATMENT
: ____________________________________________________________________
NAME OF COURT WHICH ENTERED THE ORDER
(
,
,
,
)_______________________________________________
LOCATION OF COURT
INCLUDE STREET ADDRESS
CITY
COUNTY
AND STATE
?
HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT
YES
NO
,
?
IF YES
HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
PART E VOLUNTARY ADMISSION SUBSEQUENT TO A TEMPORARY DETENTION ORDER
(
):_________________________________________________________________
DATE OF TEMPORARY DETENTION ORDER
TDO
(
),
AFTER BEING SUBJECT TO A TEMPORARY DETENTION ORDER
TDO
DID YOU SUBSEQUENTLY AGREE TO VOLUNTARY ADMISSION PURSUANT TO VA
§37.2-805?
,
: ________________________________________
CODE
YES
NO IF YES
NAME OF COURT WHICH ENTERED THE ORDER
(
,
,
,
)________________________________________________
LOCATION OF COURT
INCLUDE STREET ADDRESS
CITY
COUNTY
AND STATE
?
HAVE YOUR FIREARM RIGHTS BEEN RESTORED BY A COURT
YES
NO
,
?
IF YES
HAVE FIVE YEARS ELAPSED SINCE THE DATE OF RESTORATION
YES
NO
,
.
IF YES
ATTACH SUPPORTING DOCUMENTATION
2