Date:

Board of Firearms Permit Examiners

165 Capitol Ave., Suite 1070

Hartford, CT 06106

Dear Board Members,

I would like to appeal the revocation / denial  of my pistol permit.  (Please circle one)

My permit was revoked / denied on ___________(date on top of letter received)

Signature:

Print your name:

Address: (street, town, state, zip)

Date of Birth: ____/____/______

Phone numbers:

Home (_____) ______-_______

Work  (_____) ______-_______

Cell    (_____) ______-_______

Email address:

If you have a copy of the letter of denial or revocation sent to you by the police, please send a copy along with this letter.