Policy Text
Revised 12/13 University of California CCW Form
University of California
Retired Officer ’s Application and Certification
to
Carry a Concealed Firearm Date of Application:
Application for :
Original ID Card
ID Card Renewal
CCW
Endorsement
Requesting Qualified Retired Officer
Name: (Last, First, Middle) Driver ’s License #/State :
Date of Retirement:
Home Address: ( Number, Street , City, State, Zip Code)
Home Phone #:
Cell Phone #:
Current Endorsement Expiration Date:
E-mail Address:
Date of Birth:
Hair Color:
Eye Color:
Weight:
Height:
Race:
Sex:
Purpose of Form
To confirm h onorably retiring peace officers of this Department are authorized to carry a concealed firearm in
accordance with the laws of the S tate of California (Penal Code sections 25450 -25470; 25900 -25925; 26300- 26325 )
and Department policy.
Waiver and Release
(READ AND INITIAL NEXT TO THE FOLLOWING DECLARATIONS AND SIGN BELOW .)
(INITIAL)
_______ I am honorably retired from service in good standing with the University of California, and I am eligible to
carry a concealed firearm pursuant to state law .
_______ I recognize the University of California is not legally required to provide me with handgun instruction or a
firearms qualification course. I also recognize nothing in this application or process creates a property right to
carry a concealed firearm. I agr ee to indemnify and hold harmless the University of California and my former
employer, the University of California Police Department, and/or its agents and employees, for any injury
suffered by me or caused by my participation in this qualification proces s.
_______ I recognize it is my responsibility to review and become familiar with the state laws pertaining to carrying a
concealed firearm.
_______ Further more , I hereby specifically agree to indemnify and hold harmless the University of California and my
former employer, the University of California Police Department , and/or its officers and employees from any
and all liability resulting from my carrying and/or use of any weapon allowed under state law.
_______ I specifically authorize the University of California to release any and all protected information , including
medical information , it may possess, as it may relate to my application under state law as an honorably retired
peace officer.
I affirm that all information contained herein is true and accurate. I have read and understand the Waiver and Release.
Applicant Name (Print): Applicant Signature: Date:
Campus:
Berkeley
Davis
Irvine
Los Angeles
Merced
Riverside
San Diego
San Francisco
Santa Barbara
Santa Cruz
Revised 12/13 University of California CCW Form
Declaration of Eligibility and Certification of Qualification
(READ AND INITIAL NEXT TO THE FOLLOWING DECLARATIONS AND SIGN BELOW .)
DECLARATION OF ELIGIBILITY QUALIFICATIONS
The a pplicant :
(INITIAL)
_______ Honorably retired from service in good standing with a University of California Police Agency as a peace
officer, other than for reason of mental disability.
_______ Before such separation from service, was authorized by law to engage in or supervise the prevention,
detention, investigation or prosecution of or the incarceration of any person for any violation of law and
had statutory powers of arrest.
_______ Has not bee n officially found by a qualified medical professional employed by the agency to be
unqualified for reasons relating to mental health.
_______ Has not entered into an agreement with the agency from which the individual is separating , in which that
indiv idual acknowledges he /she is not qualified under this section for reasons relating to mental health.
_______ Will not be under the influence of alcohol or another intoxicating or hallucinatory drug or substance at
any time while carrying a firearm and i s not a habitual user of same.
_______ IS NOT PROHIBITED BY STATE LAW OR FEDERAL LAW FROM RECEIVING OR POSSESSING A FIREARM.
_______ Acknowledge s that honorably retired peace officers who elect to and are approved for a CCW
endorsement shall remain in the California Department of Justice Summary Criminal History Information
Database, pursuant to Penal Code section 11105(k ) (1).
CERTIFICATION OF FIREARMS QUALIFICATION REQUIREMENT
_______ Prior to retirement, a q ualified , honorably retiring peace officer must have met the standards for
qualification in firearms training for active law enforcement officers, as determined by his/her agency .
IF CARRYING A CONCEALED FIREARM, YOU MUST BE IN POSSESSION OF :
_______ A photographic identification issued by the University of California stating you honorably retired from
service in good standing as a peace officer with a CCW endorsement .
UNIVERSITY OF CALIFORNIA POLICE DEPARTMENT RENEWAL REQUESTS
Honorably r etired University of California peace officers with a CCW endorsement must petition their retiring
agency’s Chief of Police every five years for a renewal of the CCW endorsement on their ID card. Renewal
requests are the responsibility of the retiree and are to be sent, in writing, to the Chi ef of Police for review and
approval . State law does not require an honorably retired peace officer to participate in a firearms qualification
process after the initial CCW