FORM 201 2021
PLEASE READ THE NOTES CAREFULLY (PAGES 13-16) BEFORE COMPLETING THE APPLICATION FORM
You may type your responses except where your signature is required. Otherwise, you must use black ink and write in BLOCK
CAPITALS throughout, except when signing. A continuation sheet is provided at page 7 for further information.
I am applying for (tick each box which applies)
Firearm certificate Grant Renewal Shotgun certificate Grant Renewal
Do you wish to apply for a shotgun certificate which will expire at the same time as your firearm certificate? Yes No
PART A: Personal details.
1. Gender Male Female
2. Title ......................................................................................
3. Surname ..............................................................................
4. Forenames (state all) ...........................................................
5. If you have at any time used a name other than that given
in answer to questions 3 and 4 please complete below:
Previous surname(s) ................................................................
Previous forename(s) ..............................................................
6. Home address ......................................................................
..................................................................................................
..................................................................................................
a. Postcode ..............................................................................
b. Home tel number ................................................................
c. Mobile number ....................................................................
d. Home E-mail ........................................................................
Any previous home addresses in the last 5 years?
Yes No (If yes please give details on page 3)
7. Height ..................................................................................
8. Date of Birth ........................................................................
a. Place of birth ........................................................................
b. Nationality ...........................................................................
9. Occupation ..........................................................................
a. Work address .......................................................................
..................................................................................................
b. Postcode ..............................................................................
c. Work tel number ..................................................................
d. Work E-mail .........................................................................
PART B: Personal health & medical declaration
If necessary, continue on page 7
Important: Read notes 4-14 before completion.
10.
Have you ever been diagnosed with or treated for any of
the medical conditions in note 5?
Yes (Please provide details) No
..................................................................................................
11.
Details of your GP or GP practice
a. Name ....................................................................................
b. Address .................................................................................
..................................................................................................
..................................................................................................
c. Postcode ...............................................................................
d. Tel number ...........................................................................
e. E-mail ....................................................................................
12.
Details of all previous GP practices during the past
10 years (see note 14). Continue on page 7 if necessary.
a. Name ....................................................................................
b. Address .................................................................................
..................................................................................................
c. Postcode ...............................................................................
d. Tel number ...........................................................................
e. E-mail ....................................................................................
Are there any periods in the past 10 years when you have
not been registered with a UK GP or have consulted medical
practitioners other than at your GP practice?
Yes (Please provide details on continuation page) No
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM AND/OR
SHOTGUN CERTIFICATE
Page1
FORM 201 2021
Duty of confidentiality I will arrange for a suitably qualified GMC-registered doctor* to provide factual information to
the police about any relevant medical conditions related to my suitability to possess a firearm or shotgun. I understand
that the doctor may share my medical records with the police to enable them to make a fully informed decision on my
application, or on my continued suitability to possess a firearm or shotgun while the certificate remains valid, and I
consent to this sharing of my medical records for confidentiality purposes. I understand that I am expected to inform
the police if I am diagnosed with, or treated for, a medical condition listed in note 5 while the certificate remains valid.
*A doctor with a full, specialist or GP (rather than provisional) GMC registration and a licence to practise.
Applicant’s name (BLOCK CAPITALS)
Signature
Date
Page2
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signature
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FORM 201 2021
PART C: Offences
Important: Please read notes 15 and 16 before completion
13.
Have you been convicted of any offence (including speeding but not including parking offences or fixed penalty notices)
or received a written caution?
Yes No
If yes, give details of all convictions and/or formal written police cautions, bindovers and spent convictions, including those
received outside Great Britain.
Date Offence
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
Previous home address(es) from the past five years:
Address 1
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From .............................................. To .............................................
Address 2
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From .............................................. To .............................................
Address 3
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From .............................................. To .............................................
Page3
FORM 201 2021
PART D: Firearm details (if applicable). (If applying for a SHOTGUN certificate only go to part E)
14.
Details of firearms currently held. IMPORTANT: Please read notes 21 and 22 before completion
If none write NONE here:
Calibre
Metric/Imperial
Type
Make e.g. Winchester
Serial No/identification number
and the unique identifying
mark as applied to the firearm’s
frame or receiver and, where
different, the unique
identifying mark as applied to
each relevant component part
Reason e.g. Target, vermin
(please provide land/club
details)
15.
Details of firearms to be acquired. IMPORTANT: Please read notes 21 and 22 before completion
If none write NONE here:
Calibre Metric/Imperial
Type
Reason e.g. Target, vermin (please provide land/club details)
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM CERTIFICATE
Page4
FORM 201 2021
16.
Details of the maximum amount of ammunition to be possessed
Calibre Metric/Imperial
Quantity
Calibre Metric/Imperial
Quantity
17.
Details of current (or in the case of a grant, proposed) security arrangements
a.
Are the security arrangements at your home address? Yes No - please provide details
........................................................................................................................................................................................................
b.
Type of security:
cabinet clamp gun room other - please provide details
........................................................................................................................................................................................................
c.
Is the security shared with another certificate holder? Yes - please provide details No
........................................................................................................................................................................................................
d.
Ammunition storage please provide details
........................................................................................................................................................................................................
Page5
FORM 201 2021
PART E: Shotgun details (if applicable).
18.
Details of shotguns currently held.
If none write NONE here
Calibre/Bore or gauge
Action/Type
Make
Serial No/identification
number and the unique
identifying mark as applied to
the shotgun’s frame or
receiver and, where different,
the unique identifying mark as
applied to each relevant
component part
19.
Details of current (or in the case of a grant, proposed) security arrangements
a.
Are the security arrangements at your home address? Yes No - please provide details
........................................................................................................................................................................................................
b.
Type of security:
cabinet clamp gun room other - please provide details
........................................................................................................................................................................................................
c.
Is the security shared with another certificate holder? Yes - please provide details No
........................................................................................................................................................................................................
APPLICATION FOR THE GRANT OR RENEWAL OF A SHOTGUN CERTIFICATE
Page6
FORM 201 2021
Please use this space for any additional information relating to parts A-E of this form:
........................................................................................................................................................................................................
CONTINUATION SHEET
Page7
FORM 201 2021
I hereby apply for a
Firearm certificate Shotgun certificate
The information I have provided on this form is true and I understand that it is an offence under section 28A(7) of the Firearms
Act 1968 to knowingly or recklessly make a false statement for the purpose of procuring the grant or renewal of a certificate,
the maximum penalty for which is six months’ imprisonment and/or a fine. I understand that I will be subject to a check of
police records and that my details will be held electronically.
I understand that if I do not provide the required information my application cannot be processed and will be refused.
I understand that I am expected to inform the police if I am diagnosed with, or treated for, a medical condition listed in
note 5 while the certificate remains valid.
Data Protection
I understand that all information submitted will be handled in accordance with the Data Protection Act 2018 and the Freedom of
Information Act 2000 and connected legislation. I understand that information contained within my application form or obtained in
the course of deciding the application may be shared with: my doctor, other government departments, regulatory bodies or
enforcement agencies in the course of deciding the application or in pursuance of maintaining public safety or the peace.
Note: Any information shared will be shared in accordance with data sharing protocols. The police do not share your personal
details with other applicants or members of the public and treat information in connection with the application in confidence,
but individuals should be aware that the police may disclose some information in accordance with the legislation referred to
above.
Your personal data will be processed by the police force to which you apply in line with Part 3 of the Data Protection Act 2018
and as set out in the force’s Privacy Information Notice.
I have provided details of the referee/s I have enclosed the fee
I have read the Notes (pages 13-16) I have enclosed one photograph
Signature: ......................................................................................................................................................................................
Print name: ....................................................................................................................................................................................
Date: ....................................................................
If the applicant is under 18 years of age the following must be completed
Parent or
Guardian
Signature: ......................................................................................................................................................................................
Print name: ....................................................................................................................................................................................
Date: ....................................................................
DECLARATION
Page8
click to sign
signature
click to edit
click to sign
signature
click to edit
FORM 201 2021
PART F: Referee details for firearm and/or shotgun certificates. Please type or write in BLOCK CAPITALS.
See notes 1 and 2.
Please give details of a suitable person who has agreed to act as a referee for you.
1. Title ...................................................................................................................................................................................................
2. Surname ...........................................................................................................................................................................................
2a. Forename(s) ...................................................................................................................................................................................
3. Previous name(s) that you are aware the referee has been known by ...........................................................................................
4. a. Date of birth .................................................................................................................................................................................
b. Place of birth .................................................................................................................................................................................
5. Occupation .......................................................................................................................................................................................
6. Home address ...................................................................................................................................................................................
.......................................................................................................................................................................................................
.............
........................................................................................................................ Postcode ................................................................
7. Home telephone number .................................................................................................................................................................
a. Work telephone number ..................................................................................................................................................................
b. Mobile number .................................................................................................................................................................................
c. Home e-mail .....................................................................................................................................................................................
d. Work e-mail ......................................................................................................................................................................................
8. In what capacity do you know the referee? .....................................................................................................................................
9. How long has the referee known you? ............................................................................................................................................
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM AND/OR
SHOTGUN CERTIFICATE
Page9
FORM 201 2021
PART G: Second referee details. Please type or write in BLOCK CAPITALS
A second referee is ONLY required for a firearm certificate. See notes 1 and 2
Please give details of a suitable person who has agreed to act as a referee for you.
1. Title ....................................................................................................................................................................................................
2. Surname .............................................................................................................................................................................................
2a. Forename(s) .....................................................................................................................................................................................
3. Previous name(s) that you are aware the referee has been known by ..............................................................................................
4. a. Date of birth ...................................................................................................................................................................................
b. Place of birth ......................................................................................................................................................................................
5. Occupation .........................................................................................................................................................................................
6. Home address .....................................................................................................................................................................................
..........................................................................................................................................................................................................................
............................................................................................................................. Postcode ...................................................................
7. Home telephone number ..................................................................................................................................................................
a. Work telephone number....................................................................................................................................................................
b. Mobile number ..................................................................................................................................................................................
c. Home e-mail .......................................................................................................................................................................................
d. Work e-mail .......................................................................................................................................................................................
8. In what capacity do you know the referee? ......................................................................................................................................
9. How long has the referee known you? ..............................................................................................................................................
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM CERTIFICATE
Page10
FORM 201 2021
This page is left blank to allow the
equality information to be detached from
the rest of the application.
Page11
FORM 201 2021
PART H: Equality (Please tick the appropriate
boxes)
EQUALITY INFORMATION
1. I would prefer not to answer any of the
following questions.
2. Do you have a disability?
Yes No
Prefer not to say
3. What is your ethnic group?
A. White
English
Welsh
Scottish
Northern Irish
British
Irish
Gypsy or Irish Traveller
Any other white background, write in:
.................................................................................
B. Mixed/multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other mixed/multiple ethnic
background, write in:
.................................................................................
C. Asian or Asian British
Indian
Pakistani
D. Black/African/Caribbean/Black British
African
Caribbean
Any other Black/African/Caribbean
background, write in:
.................................................................................
E. Other ethnic group
Arab
Any other ethnic group, write in:
.................................................................................
F. Prefer not to say
4. Gender
Male Female
Prefer not to say
5. What is your age group?
Age group
Tick
66 and above
61-65
56-60
51-55
46-50
41-45
36-40
31-35
26-30
21-25
18-20
Under 18
Prefer not to say
Bangladeshi
Chinese
Any other Asian background, write in:
.................................................................................
Page12
FORM 201 2021
You must complete all parts of the form for the type of certificate for which you are applying. For
electronic applications, each data field must be completed.
FIREARM: Section 1 of the Firearms Act 1968 (as
amended) applies to all firearms except:
i. a shotgun;
ii. an air weapon (unless declared specially
dangerous);
iii. prohibited weapons such as centre fire self-
loading rifles, handguns, machine guns etc
(unless specifically authorised).
SHOTGUN: Section 1(3)(a) of the Firearms Act 1968
(as amended) defines a shotgun as:
i. a smooth bore gun (not being an air
weapon);
ii. having a barrel not less than 24’’ (60.96cm)
in length and a bore not exceeding 2’’
(5.08cm) in diameter;
iii. either having no magazine, or a non-
detachable magazine incapable of holding
more than two cartridges;
iv. not a revolver gun.
Referees
1. When applying for a firearm certificate, you should have gained the permission of two people who
have agreed to act as referees for you. You must complete Parts F and G with their details. When
applying for a shotgun certificate you should have gained the permission of one person to act as a
referee for you. You must complete part F with their details.
2. The referee(s) who have agreed to act for you must have known you personally for at least two years and
must be resident in Great Britain. A referee must not be a member of your immediate family, a registered
firearms dealer, a serving police officer, a police employee, a Police and Crime Commissioner or a
member of their staff, or a member of, or a member of staff of, the Scottish Police Authority. Referees
must be of good character and any references they agree to provide must be given freely and not on
payment.
Coterminous applications
3. To apply for both a firearm certificate and a shotgun certificate and to have them expire at the
same time (coterminous certificates) you should complete the sections for firearm and shotgun
certificates. The fee payable for such certificates may be less than the normal fee for the grant or
renewal of a shotgun certificate if both of your applications are dealt with at the same time.
Medical information
4. You must disclose any relevant physical or mental health conditions that you have been
diagnosed with or treated for in the past as this may affect your ability to safely possess and use
a firearm or shotgun. Relevant medical conditions which must be disclosed are listed in note 5.
Sections 27 and 28 of the Firearms Act 1968 (as amended) specify that in order to issue a firearm
or shotgun certificate the chief officer of police must be satisfied that an applicant can be
permitted to possess a gun ‘without danger to the public safety or the peace’. Medical fitness
is one of the factors police must consider when assessing a person’s suitability.
NOTES
Please read these BEFORE completing the form
Page13
5. Relevant medical conditions which must be disclosed are:
Acute Stress Reaction or an acute reaction to the stress caused by a trauma, including post-
traumatic stress disorder
Suicidal thoughts or self harm or harm to others
Depression or anxiety
Dementia
Mania, bipolar disorder or a psychotic illness
A personality disorder
A neurological condition: for example, Multiple Sclerosis, Parkinson’s or Huntington’s
diseases, or epilepsy
Alcohol or drug abuse
Any other mental or physical condition, or combination of conditions, which you think may
be relevant.
If in doubt, consult your doctor or contact the police firearms licensing department.
6. It is your responsibility to arrange for your GP or another suitably qualified GMC-registered
doctor* (including where a doctor is providing this service for a private company) to provide
medical information to the police concerning your suitability to possess a firearm and/or
shotgun. Please use the doctor's letter and medical information proforma which is part of this
document, detach and pass to the doctor for completion. You are expected to meet the cost if a
fee is charged for this. When the medical information is being provided to the police by a
doctor from a private company, the doctor must receive the applicant's medical information
direct from the GP practice and not via the applicant.
7. With regards to data protection, it should be noted that the medical information will be
processed on a public interest basis for the legitimate policing purpose of assessing the
suitability of someone to be granted a firearm or shotgun certificate.
8. Medical practitioners have separately requested that an applicant's consent is provided in order
for medical practitioners to be satisfied that they have discharged their obligations under their
duty of confidentiality in relation to their patients. The application form requests the applicant's
consent for the release of the information for that reason.
9. Where the doctor indicates that there are relevant medical issues and police require further medical
information to consider the application, you should obtain a report about these medical issues. You
are expected to meet the cost of a fee if it is charged. Following this, if police require an additional
report to be provided they will meet the cost of the fee charged.
10. The police will ask your GP to place an encoded reminder on your patient record to indicate that
you have been issued with a firearm or shotgun certificate. The GP is asked to notify the police
if, following issue of the certificate, you are diagnosed with or treated for a relevant medical
condition (listed in note 5), or if the GP has other concerns about your possession of a certificate
that might affect your safe possession of firearms. Following contact from your GP there may be
a need for a medical report to be obtained to assist with assessment of your continued suitability
to possess a firearm or shotgun certificate. The police will pay if a medical report is required.
11. Following the issue of a firearm or shotgun certificate please note that the declaration you have
signed consenting to information sharing between your doctor and police applies during the
application process and during the validity of any firearm or shotgun certificate, which may be
up to five years.
12. You are expected to inform the police if, following issue of the certificate, you are diagnosed
with or treated for a relevant medical condition while the certificate remains valid.
Page14
13. You should inform the police if you change your GP practice and provide contact details for the
new practice.
14. You are asked to provide details of GP practices over the past 10 years and whether you have
consulted medical practitioners other than at your GP practice so that all relevant information is
available to police to assist with their assessment of suitability to possess a firearm certificate.
Military personnel who are posted abroad and have a service GP may still be regarded as
resident in the UK for the purposes of the application.
Convictions and offences
15. You must not withhold information about any conviction. This includes motoring offences
(including speeding offences), bindovers, formal written cautions and convictions in and outside
Great Britain, and (by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975)
convictions which are spent under the 1974 Act. A conditional discharge and an absolute discharge
both count as convictions for this purpose. Details of parking offences and fixed penalty notices do not
need to be declared.
16. Section 21 of the Firearms Act 1968 places restrictions on the possession of firearms and
ammunition by those previously convicted of crime. A person receiving a sentence of
imprisonment of three months or more is prohibited from possessing a firearm, shotgun, antique
firearm, air weapon or ammunition for five years from the date of their release. In the case of
a suspended sentence the prohibition applies from the second day after being sentenced. If the
sentence is three years or more the prohibition applies for life unless lifted by the Crown
(or Sheriff) Court.
Inspection of premises
17. Please allow the police to inspect your guns and security when requested as in the absence of a
warrant consent is required for the police to inspect premises.
Photograph
18. A digital photograph must be used for online applications. Paper applications must be accompanied by
one photograph. Ordinary passport-style photographs (45mm high x 35mm wide) are suitable for this
purpose. Photographs must be of a professional standard, against a plain cream or grey background
and without other objects or people in the background and (if printed) must be on good quality gloss or
matt paper. The photograph must be a true likeness and full face without a head covering (unless it is
worn for religious or medical reasons). In your photograph you must be looking straight at the camera,
have a neutral expression, with your eyes open and mouth closed. You must not wear sunglasses or
tinted glasses, and the photographs must not have any ‘red eye.
Equality monitoring
19. The equality monitoring information you provide in Part H aims to assist the force in meeting its duties
as a Public Authority. The information will be kept separately from the application.
Submission of application
20. The receipt for electronic applications, where these are available, will be automatically generated by
the system. For hard copy applications, unless advised otherwise by the police, you should post or take
the completed form together with the fee and photograph to the police firearms licensing department.
In the case of an application for renewal, a signed and dated recent copy of the certificate to be
renewed should be sent to police when you submit your application. If an application is being made for a
variation the certificate to be varied must be included with your application. (You may wish to keep a
copy of the certificate.)
Page15
Section 1 Firearms Only
21. To acquire or possess firearms or ammunition under section 1 of the Firearms Act 1968, you have to
provide evidence that you have a good reason to do so. This applies to the grant, renewal or variation of
a firearm certificate. This evidence can take several forms: permission to shoot over land or
membership of a target shooting club, or a booking or invitation to go deer stalking are examples, but
these are not exhaustive.
22. Please provide the address of one area of land where you have permission to shoot, together with the
name, address and telephone number of the person who has given you that permission or the details of
a Home Office approved club of which you are a full member.
NB: You will not necessarily be limited to shooting over that individual piece of land or at that club.
*A doctor with a full, specialist or GP (rather than provisional) GMC registration and a licence to practise.
Page16
This page is left blank to allow the
doctors letter and medical information
proforma to be detached from the rest of
the application.
Doctor’s Name:
Applicant’s Name:
Address
Date of Birth:
Address:
Post Code:
Post Code:
Phone Number:
E-mail address:
Dear Doctor,
I am applying for a firearm certificate/shotgun certificate/to be registered as a firearms dealer.
Firearms applications and medical fitness
The police assess firearms applications and require all applicants to provide factual information from a doctor
confirming whether they have ever been diagnosed with or treated for any of the following conditions, which can
have a bearing on whether a person is suitable to be granted a firearm certificate:
Acute Stress Reaction or an acute reaction to the stress caused by a trauma, including post-traumatic stress
disorder
Suicidal thoughts or self-harm or harm to others
Depression or anxiety
Dementia
Mania, bipolar disorder or a psychotic illness, or a personality disorder
A neurological condition: for example, Multiple Sclerosis, Parkinson’s or Huntington’s diseases, or epilepsy
Alcohol or drug abuse
Any other mental or physical condition, or combination of conditions, which you think may be relevant.
Please note that the police are not seeking your opinion on my suitability to hold a firearm certificate, as the
responsibility for this decision lies with the police. They require only a factual response, from a suitably qualified
GMC-registered doctor* based on my medical record.
*A doctor with a full, specialist or GP (rather than provisional) GMC registration and a licence to practise.
Information requested from a GMC-registered doctor
If there is a history of any of the relevant medical conditions listed, please can the response include the following:
1. Name of medical condition
2. Duration of medical condition
3. Medication prescribed
Please note that only information about any relevant medical condition(s) should be provided. A print out of my
medical history is therefore not acceptable for this purpose.
Doctors’ fees
Should a fee be payable, please forward an invoice to my home address. I understand that the information will not
be provided until the fee, if any, has been paid.
How to respond
Your response should be sent to the local police firearms licensing department by secured NHS email, or sent by
post. Alternatively, please contact me so that I can collect it. If the response is given to me to supply to the police
they may contact you to confirm the details.
When the medical information is being provided to the police by a doctor from a private company, the doctor must
receive the applicant’s medical information direct from the GP practice and not via the applicant.
Once the police have considered your response, they may wish to see a medical report about any relevant medical
conditions I have experienced so that they can give further consideration to my application. I will be liable for the
medical fees to provide a report.
Firearms marker
Please put a ‘firearm application made’ flag on the patient record. If I am granted a firearm certificate the police
will contact you to ask you to place a ‘firearm certificate held’ flag on my patient record. This is so that the police
can be alerted if I begin to experience any of the relevant medical conditions listed while the firearm certificate
remains valid. The police will then review my suitability to continue as a firearm certificate holder.
Further information
If you need any further information, please telephone or email the local police firearms licensing department.
Thank you for your assistance.
Yours sincerely,
Applicant signature
CONSENT
I understand that a doctor may share sensitive personal data with the police concerning my physical and mental health
to enable the police to make a decision on my application, or on my continued suitability to possess a firearm certificate,
and I hereby consent to this processing of my personal data.
I understand that the police will process the medical information supplied on a public interest basis for the legitimate
policing purpose of assessing the suitability of someone to be granted a firearm or shotgun certificate.
I understand that medical practitioners have requested that my consent is provided in respect of their duty of
confidentiality to allow doctors to provide information to the police, who will then process the data as described above.
I understand the police may contact my doctor or medical specialist to obtain factual details of any medical history in
relation to my suitability to possess a firearm or shotgun. This applies for the life of the certificate.
CONFIDENTIAL MEDICAL (when complete)
Firearms Licensing
Medical Information Proforma
This form must not be amended after completion by the doctor*. The Firearms Act 1968 specifies that it is an
offence to knowingly or recklessly make a false statement for the purpose of procuring the grant or renewal of a
certificate, with a maximum penalty of six months imprisonment and/or a fine.
PATIENT DETAILS
Title:
Full Name:
Home Address:
Date of Birth:
E-mail address:
MEDICAL INFORMATION: To be completed by doctor*
*A doctor with a full, specialist or GP (rather than provisional) GMC registration and a licence to practise.
Please check the patient's medical record for any history of the following and tick those that apply. Where any apply,
please add further details overleaf which can be limited to a statement of fact and not an opinion.
Have you had access to the patient’s full medical record to complete this report? Yes No
Is the medical record continuous? Yes No
Have you placed a ‘firearm application made’ flag on the patient record? Yes No
DATE RECORDS BEGIN:
DATE OF LAST CONSULTATION:
Acute Stress Reaction or an acute
reaction to the stress caused by a
trauma, including post-traumatic
stress disorder
Yes No
A personality disorder
Yes No
Suicidal thoughts or self-harm or harm
to others
Yes No
A neurological condition: for
example, Multiple Sclerosis,
Parkinson’s or Huntington’s
diseases, or epilepsy
Yes No
Depression or anxiety
Yes No
Alcohol or drug abuse
Yes No
Dementia
Yes No
Any other mental or physical
condition, or combination of
conditions, which may affect
the safe possession of
firearms or shotguns.
Yes No
Mania, bipolar disorder or a psychotic
illness
Yes No
PLEASE SIGN OVERLEAF. PLEASE PROVIDE FURTHER INFORMATION IF YOU HAVE TICKED YES TO ANY OF THE ABOVE
QUESTIONS.
CONFIDENTIAL MEDICAL (when complete)
CONFIDENTIAL MEDICAL (when complete)
Name of doctor:
Practice stamp:
Signature of doctor:
GMC Number:
Date:
CONFIDENTIAL MEDICAL (when complete)
Patient Name:
Date of birth:
What is the medical condition or medical conditions?
How long has the patient been treated for this condition?
Is the patient still being treated for this?
Details of medication prescribed
Have there been any previous episodes of this?
What is the patient’s current condition?
Do you have any other information you believe may be relevant to the police in determining whether the patient is
safe to possess firearms?