FORM 201V – 2021
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 4 for further
information.
NOTE: THE CERTIFICATE TO BE VARIED MUST BE ENCLOSED WITH THIS FORM
Form 201 contains notes which may be helpful in completing this form
PART A: Personal details
1. Gender
Male
Female
2. Title ....................................................................................
3. Surname ............................................................................
a. Previous surname(s) ..........................................................
................................................................................................
4. Forenames (state all) .........................................................
................................................................................................
5. Home address ....................................................................
................................................................................................
................................................................................................
a. Postcode ............................................................................
b. Home tel number ..............................................................
c. Mobile number ..................................................................
d. Home E-mail ......................................................................
6. Height ................................................................................
7. Date of Birth ......................................................................
a. Place of birth .....................................................................
b. Nationality .........................................................................
8. 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 4
9. Have you ever been diagnosed with or treated for any of
the following relevant medical conditions:
• 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 GP or contact the police firearms
licensing department.
Yes
(Please provide details) No
..................................................................................................
..................................................................................................
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10. Details of your GP or GP practice
a. Name ...................................................................................
b. Address ................................................................................
..................................................................................................
..................................................................................................
c. Postcode ..............................................................................
d. Tel number ..........................................................................
e. E-mail ...................................................................................
APPLICATION TO VARY A FIREARM CERTIFICATE