If any portion of 515 CMR 6.00 is for any reason held to be unconstitutional, contrary to statute, in excess of the authority of the Colonel of the Massachusetts State Police or otherwise inoperative, such decision shall not affect the validity of any other portion or 515 CMR 6.00.

REGULATORY AUTHORITY

515 CMR 6.00: M.G.L. c. 140, § 131(r) and 18 U.S.C. c. 44.

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RETIRED LAW ENFORCEMENT OFFICER APPLICATION FOR FIREARMS CERTIFICATION

Name: ___________________________________________________________________________

(First) (Last) (M.I)

Home Address:

_________________________________________________________________________________

(Street) (State) (Zip Code)

DOB: _____________ LTC #: _____________________________

Name of Law Enforcement Agency from which applicant retired:

______________________________________________________

I understand that in order to carry a concealed firearm as a qualified retired law enforcement officer in accordance with 18 U.S.C. § 926C, I must satisfy certain basic criteria.

The law enforcement agency from which I retired has issued me a photographic identification.

I retired in good standing from a public agency as a law enforcement officer.

I did not retire for reasons of mental instability.

I was authorized to engage in or supervise the prevention, detection, investigation or prosecution of, or the incarceration of any person for, any violation of law, and I had statutory powers of arrest.

Before retirement, I was regularly employed as a law enforcement officer for 15 or more years aggregated, or retired after completing probation due to service-connected disability as determined by the agency I retired from. I have a non-forfeitable right to benefits under my agency’s retirement plan.

I am not now under the influence of alcohol or another intoxicating or hallucinatory drug or substance, and I will not carry a firearm while I am under the influence of alcohol or another intoxicating or hallucinatory drug or substance.

I am not prohibited by state or federal law from receiving a firearm. I understand that the definition of “firearm” does not include any machine gun, firearms silencer, or destructive device.

I understand that I must carry the Massachusetts LEOSA certification, along with a photographic identification issued by my agency, when I carry the concealed weapon.

I understand that my certification expires 12 months from its issue date.

I understand that the Law Enforcement Officers Safety Act of 2004, 18 U.S.C. § 926C, does not give me any rights whatsoever to exercise law enforcement authority or take police action under any circumstances.

I do hereby declare and affirm under the penalties of perjury that the contents of this application are true and correct to the best of my knowledge, information, and belief and I so indicate by signing below in the designated space.

___________________________________ ________________

Applicant Signature Date

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