FORM 201 – 2017 - 1
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 …………………………………………….………………….