Fillable FIREARMS INFORMATION FORM

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FIREARMS INFORMATION FORM

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PERMIT NO. ______________________
FIREARMS INFORMATION FORM
R Rifle/Shotgun Acquisition R Out-of-State Firearm Acquisition R Return of Firearm
from Evidence
Name_____________________________________________________________________________________________
LAST FIRST MIDDLE (MAIDEN NAME)
Address_______________________________________________________________ Phone ____________________
Employer ___________________________________________________________ SSN ______________________
Business address ________________________________________________________ Phone ____________________
Occupation _____________________________________________________ Rank/grade (military) ______________
Date of birth ____________________ Sex _______ Place of birth _________________________________________
U.S. passport/naturalization No. _________________________________ U.S. citizen YES R NO R
Racial extraction ______________ Height ' " Weight ______ Hair ___________ Eyes ______________
Acquired from: Name ____________________________________________________ Phone ____________________
Address ______________________________________ Deceased YES R NO R
Brought in from: ____________________________________________________________________________________
CITY AND STATE (OR CITY AND COUNTRY)
Caliber Make Model Type Barrel length Serial No.
(Hand/Rifle/Shotgun) indicate action
1. ________________________________________________________________________________________________
2. ________________________________________________________________________________________________
3. ________________________________________________________________________________________________
4. ________________________________________________________________________________________________
5. ________________________________________________________________________________________________
6. ________________________________________________________________________________________________
7. ________________________________________________________________________________________________
________________________________________ ______________________ __________________________
SIGNATURE OF APPLICANT DATE/TIME TYPE OF IDENTIFICATION
_______________________________________________
WITNESS
_______________________________________________
PERFORMED COMPUTER CHECKS
PHOTO
RIGHT THUMB PRINT
HPD-84 (R-05/13)
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Completed 2 January 2021

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