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Ii G <br />15. Demonstrable Need Criteria: <br />As required by Section 2 (f) of Ordinance No. 79-27, as <br />amended, please state those facts which affirmatively <br />establish the propriety of use of or the necessity for <br />carrying a concealed handgun: <br />16. List the names and addresses of three individuals who are not <br />related to you by blood or marriage who may be contacted for <br />information as to your moral character, fitness and <br />eligibility for this license. <br />1. <br />2. <br />3. <br />CERTIFICATION AND AUTHORIZATION FOR P';LEASE OF INFORMATION <br />I HEREBY CERTIFY THAT ALL INFORMATION AND ANSWERS CONTAINED <br />IN THIS APPLICATION ARE TRUE AND CORRECT AND I AM AWARE THAT ANY <br />FRAUD OR DECEIT IN CONNECTION WITH THIS APPLICATION SHALL <br />CONSTITUTE GROUNDS FOR REVOCATION OF MY LICENSE, AND FORFEITURE OF <br />ANY SURETY BOND POSTED FOR SAID LICENSE. <br />I HEREBY FURTHER AUTHORIZE THE BOARD OF COUNTY COMMISSIONERS <br />OR AN OFFICIAL DESIGNATED BY THEM TO REQUEST, OBTAIN, AND REVIEW <br />ANY AND ALL RECORDS OR INFORMATION WHICH MAY REASONABLY PERTAIN TO <br />MY MENTAL OR PHYSICAL FITNESS OR ELIGIBILITY FOR ISSUANCE OF `PHIS <br />LICENSE, AND I SPECIFICALLY DIRECT AND AUTHORIZE THE CUSTODIAN OF <br />ANY SUCH RECORDS OR INFORMATION, INCLUDING BUT NOT LIMITED TO <br />PHYSICIANS, HOSPITALS, INSURANCE COMPANIES, LAW ENFORCEMENT <br />AGENCIES, OR PAST OR PRESENT EMPLOYERS, TO RELEASE SAID <br />INFORMATION UPON REQUEST BY THE COUNTY FOR THE LIMITED AND <br />EXCLUSIVE PURPOSE OF REVIEWING THIS APPLICATION. <br />DATE: <br />Signature of Applicant <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />Sworn to and subscribed before me this day of <br />19 . <br />Notary Public <br />My Commission Expires: <br />-3- <br />