WARNING: You may not receive a firearm if prohibited by Federal or State law. The information you provide will be used to
determine whether you are prohibited from receiving a firearm. Certain violations of the Gun Control Act, 18 U.S.C. 921
et. seq., are punishable by up to 10 years imprisonment and/or up to a $250,000 fine.
Read the Notices, Instructions, and Definitions on this form. Prepare in original only at the licensed premises (“licensed premises”
includes business temporarily conducted from a qualifying gun show or event in the same State in which the licensed premises is
located) unless the transaction qualifies under 18 U.S.C. 922(c). All entries must be handwritten in ink. “PLEASE PRINT.”