CPL Renewal Introduction and Registration.

5, 0LFKLJDQ 6WDWH 3ROLFH 3DJH RI

III. Survey (continued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

1R

1R

1R

1R

1R

1R

$UH \RX XQGHU D FRXUW RUGHU RI OHJDO LQFDSDFLW\ LQ WKLV VWDWH RU HOVHZKHUH"

1R

+DYH \RX HYHU EHHQ GLVKRQRUDEO\ GLVFKDUJHG IURP WKH 8QLWHG 6WDWHV $UPHG )RUFHV"

1R

+DYH \RX FRPSOHWHG WKH WUDLQLQJ UHTXLUHG IRU D QHZ &3/ GRFXPHQWDWLRQ PXVW EH SUHVHQWHG ZLWK WKH DSSOLFDWLRQ OR KDYH \RX FHUWLILHG DERYH WKDW \RX KDYH FRPSOHWHG WKH UHTXLUHG UHYLHZ DQG ILULQJ UDQJH WLPH IRU D UHQHZDO RI \RXU OLFHQVH"

1R

$UH \RX D UHWLUHG SROLFH RIILFHU RU UHWLUHG ODZ HQIRUFHPHQW RIILFHU" $UH \RX H[HPSW IURP SURKLELWHG SUHPLVHV SXUVXDQW WR 0&/

1R

R" ,I \HV DFFHSWDEOH SURRI PXVW EH SURYLGHG WR WKH

1R

FRXQW\ FOHUN SXUVXDQW WR 0&/

E D

V. Agreement and Certification %\ VLJQLQJ EHORZ \RX DFNQRZOHGJH WKH IROORZLQJ VWDWHPHQWV DUH WUXH x , KDYH UHDG WKH LQIRUPDWLRQ SURYLGHG RQ FDUU\LQJ D FRQFHDOHG SLVWRO DQG REWDLQLQJ D 0LFKLJDQ &3/ , PHHW DOO WKH FULWHULD IRU REWDLQLQJ D &3/ DQG , GR QRW KDYH D KLVWRU\ RI PHQWDO LOOQHVV WKDW ZRXOG GLVTXDOLI\ PH IURP REWDLQLQJ D &3/ XQGHU WKH )LUHDUPV $FW 3$ DV DPHQGHG x , JLYH DXWKRULW\ WR WKH 063 WR DFFHVV DQ\ UHFRUG QHHGHG WR SHUIRUP LWV UHTXLUHG YHULILFDWLRQ WKURXJK WKH /DZ (QIRUFHPHQW ,QIRUPDWLRQ 1HWZRUN /(,1 DQG WKH 1DWLRQDO ,QVWDQW &ULPLQDO %DFNJURXQG &KHFN 6\VWHP 1,&6 x , XQGHUVWDQG WKDW P\ SHUVRQDO LQIRUPDWLRQ DQG ELRPHWULF GDWD EHLQJ VXEPLWWHG E\ /LYHVFDQ ZLOO EH XVHG WR VHDUFK DJDLQVW LGHQWLILFDWLRQ UHFRUGV IURP ERWK WKH 063 DQG )%, IRU WKH SXUSRVH RI YHULI\LQJ P\ HOLJLELOLW\ WR REWDLQ D &3/ , KHUHE\ DXWKRUL]H WKH UHOHDVH RI P\ SHUVRQDO LQIRUPDWLRQ IRU VXFK SXUSRVH DQG UHOHDVH RI DQ\ UHFRUGV IRXQG E\ WKH 063 x 'XULQJ WKH SURFHVVLQJ RI WKLV DSSOLFDWLRQ DQG IRU DV ORQJ DV P\ ILQJHUSULQWV DQG DVVRFLDWHG LQIRUPDWLRQ ELRPHWULFV DUH UHWDLQHG E\ WKH 6WDWH DQG RU )%, WKH\ PD\ EH GLVFORVHG ZLWKRXW P\ FRQVHQW DV SHUPLWWHG E\ 0&/ DQG WKH 3ULYDF\ $FW RI 86& †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x I understand that intentionally making a false statement on this application is a felony punishable by imprisonment for not more than four years or a fine of not more than $2,500, or both. x , KDYH EHHQ SURYLGHG ZLWK D FRS\ RI WKH FRPSLODWLRQ RI WKH )LUHDUPV /DZV RI 0LFKLJDQ FUHDWHG E\ WKH /HJLVODWLYH 6HUYLFHV %XUHDX DQG IRUPV WR DSSHDO DQ\ QRWLFH RI VWDWXWRU\ GLVTXDOLILFDWLRQ RU VXVSHQVLRQ RU UHYRFDWLRQ RI D OLFHQVH XQGHU WKLV DFW

Applicant's Name and Signature ,I FRPSOHWLQJ WKLV IRUP LQ SHUVRQ GR QRW VLJQ XQWLO LQVWUXFWHG E\ WKH FRXQW\ FOHUN RU KLV RU KHU UHSUHVHQWDWLYH 7KLV GRHV QRW DSSO\ WR renewal DSSOLFDWLRQV LI WKH FRPSOHWHG IRUP ZLOO EH VXEPLWWHG E\ PDLO RU HOHFWURQLFDOO\ 'DWH

Witness’ Name, Title, and Signature ,I FRPSOHWLQJ WKLV IRUP LQ SHUVRQ WKH ZLWQHVV ZLOO EH WKH &RXQW\ &OHUN RU 5HSUHVHQWDWLYH $ ZLWQHVV VLJQDWXUH LV QRW QHFHVVDU\ IRU renewal DSSOLFDWLRQV LI WKH FRPSOHWHG IRUP ZLOO EH VXEPLWWHG E\ PDLO RU HOHFWURQLFDOO\

'DWH

When used as a new application, return the completed unsigned form and documentation of required training to the county clerk's office. A passport quality photograph must be submitted if a digital photograph is not on file with the Michigan Secretary of State.