FORM 2012017 - 1
Page1
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM AND/OR
SHOTGUN CERTIFICATE
PLEASE READ THE NOTES CAREFULLY (PAGES 12-15) BEFORE COMPLETING THE APPLICATION FORM
You may type your responses except where your signature is required. Otherwise, please use black ink and write in BLOCK
CAPITALS throughout, except when signing. A continuation sheet is provided at page 6 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 2)
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 6
Important: Read notes 4-12 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 12). Continue on page 6 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
I give the police permission to contact my GP and/or specialist to obtain factual details of any medical history in relation to my suitability to
possess a firearm and/or shotgun. This authority is valid for the life of the certificate(s). I understand that my GP may share sensitive
personal data with the police concerning my physical and mental health for the purpose of enabling the police to make a fully informed
decision on my application or continued suitability, and I hereby consent to this processing of my personal data.
Applicant’s name (please print)…………………….………………………………………………………………………………………………………………….……
Applicant’s signature ………………………………………………………………………………….Date …………………………………………….………………….
FORM 2012017 - 1
Page2
PART C: Offences
Important: Please read notes 13 and 14 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 Offen
ce
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
.......................................... ...............................................................................................................................................
Previ
ous home address(es) from the past five years:
Address 1
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From ..............................................
To .............................................
Address 2
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From ..............................................
To .............................................
Address 3
........................................................................................................................................................................................................
........................................................................................................................................................................................................
........................................................................................................................ Postcode .........................................................
From ..............................................
To .............................................
FORM 2012017 - 1
Page3
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM CERTIFICATE
(If applying for a SHOTGUN certificate only go to part E)
PART D: F
irearm details (if applicable).
14. Details of firearms currently held. IMPORTANT: Please read notes 19 and 20 before completion
If none write NONE here:
Calibre
Metric/Imperial
Type Make e.g. Winchester
Serial No
Reason e.g. Target, vermin
(please provide land/club details)
15. Details of firearms to be acquired. IMPORTANT: Please read notes 19 and 20 before completion
If none write NONE here:
Calibre
Metric/Imperial
Type Reason e.g. Target, vermin
(please provide land/club details)
FORM 2012017 - 1
Page4
16. Details of the maximum amount of ammunition to be possessed
Calibre
Metric/Imperial
Quantity Calibre
Metric/Imperial
Quantity
17. Det
ails 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 s
ecurity:
cabinet clamp gun room other - please provide details
........................................................................................................................................................................................................
c. Is the security shared with another certificate holder? Yes - please provide details No
........................................................................................................................................................................................................
d. Ammunit
ion storage please provide details
........................................................................................................................................................................................................
FORM 2012017 - 1
Page5
APPLICATION FOR THE GRANT OR RENEWAL OF A SHOTGUN CERTIFICATE
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
19. Det
ails 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 s
ecurity:
cabinet clamp gun room other - please provide details
........................................................................................................................................................................................................
c. Is the security shared with another certificate holder? Yes - please provide details No
........................................................................................................................................................................................................
FORM 2012017 - 1
Page6
CONTINUATION SHEET
Please use this space for any additional information relating to parts A-E of this form:
........................................................................................................................................................................................................
FORM 2012017 - 1
Page7
DECLARATION
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 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 t
hat 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 under
stand that all information submitted will be handled in accordance with the Data Protection Act 1998 and the
Freedom of Information Act 2000 and connected legislation. I understand and give consent for information contained within
my application form or obtained in the course of deciding the application to be shared with: my GP, 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
confi
dence, but individuals should be aware that the police may disclose some information in accordance with the legislation
referred to above.
I have signed the medical consent on page 1 I have enclosed the fee
I have provided details of the referee/s I have enclosed one photograph
I have read the Notes (pages 12-15)
Signat
ure: ......................................................................................................................................................................................
Print name: ....................................................................................................................................................................................
Date: ....................................................................
If the a
pplicant is under 18 years of age the following must be completed
Parent or Guardian
Signat
ure: ......................................................................................................................................................................................
Print name: ....................................................................................................................................................................................
Date: ....................................................................
FORM 2012017 - 1
Page8
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM AND/OR
SHOTGUN CERTIFICATE
PART F: Referee details for firearm and/or shotgun certificates. Please type or write in BLOCK CAPITALS.
See notes 1 and 2.
Pleas
e 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? .....................................................................................................................................
FORM 2012017 - 1
Page9
APPLICATION FOR THE GRANT OR RENEWAL OF A FIREARM CERTIFICATE
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
Pleas
e 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? .....................................................................................................................................
FORM 2012017 - 1
Page10
This page is left blank to allow the
equality information to be detached from
the rest of the application.
FORM 2012017 - 1
Page11
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
Bangladeshi
Chinese
Any other Asian background, write in:
.................................................................................
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 yo
ur 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
FORM 2012017 - 1
Page12
NOTES
Please read these BEFORE completing the form
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.
FORM 2012017 - 1
Page13
5. Relevant medical conditions which must be disclosed are:
Acute Stress Reaction or an acute reaction to the stress caused by a trauma
Suicidal thoughts or self harm
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 which might affect your safe possession of a firearm
or shotgun
If in doubt, consult your GP or contact the police firearms licensing department.
6. If you have disclosed a relevant medical condition the police may ask you to obtain a medical
report from your GP/specialist. You are expected to meet the cost if a fee is charged for this. If
further information is required the police may request and pay for a further report.
7. Where no relevant medical conditions are disclosed the police will contact your GP asking if
they are aware of any relevant medical conditions or have any concerns about the grant of the
firearm or shotgun certificate. Depending on the reply, the police may ask you to obtain a
medical report from your GP/specialist. You are expected to meet the cost if a fee is charged for
this. If further information is required the police may request and pay for a further report.
8. 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.
9. Following the issue of a firearm or shotgun certificate please note that the declaration you have
signed consenting to information sharing between your GP and police applies during the
application process and during the validity of any firearm or shotgun certificate, which may be
up to five years.
10. 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.
11. You should inform the police if you change your GP practice and provide contact details for the
new practice.
12. 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.
FORM 2012017 - 1
Page14
Convictions and offences
13. 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.
14. 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
15. 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.
Photographs
16. 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
17. 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
18. 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.)
FORM 2012017 - 1
Page15
Section 1 Firearms Only
19. 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.
20. 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.
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