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APPLICATION FOR ISSUANCE OF LICENSE <br />TO CARRY A CONCEALED FIREARM IN INDIAN RIVER COUNTY FLORIDA <br />Please print legibly or type; answer each question, indicating <br />"Yes," with full details, "No", not applicable (N/A) or NONE where <br />appropriate; please use additional sheet if necessary to answer <br />any question in its entirety; you should refer to the attached <br />instructions and criteria for guidance, if necessary. <br />1. Full name: <br />2. Present address (give both mailing address and residpnrp_ if <br />Lhuy differ) : <br />Mailing Address Residence (if different) <br />Stree <br />Street <br />City, State and Zip Code City, State and Zip Code <br />3. (a) Date of Birth: <br />(b) Place of Birth: <br />(c) Social Security No.: <br />4. Telephone Number: <br />Home: Business: <br />5. Present Occupation: <br />6. Name and Mailing Address of Present Employer (also give <br />location of principal place of business, if different than <br />business mailing address): <br />Present Employer Principal Place of. Business <br />(if different) <br />Name <br />Street Street —' <br />City, State and Zip Code City, State and Zip Code <br />7. Occupation and employers for the immediate past four (4) years <br />(give same information as question No. 6 and give dates): <br />8. <br />List the following information for each weapon you wish to <br />carry pursuant to this license. <br />(a) Make of weapon <br />(b) Caliber <br />(c) Serial Number <br />(d) Length of barrel <br />(e) Type (automatic/revolver) <br />-1- <br />EXHIBIT A <br />