A. PERSONAL DETAILS
If this application is for a minor (12 - 18 yrs), the minor completes their details and must record their parent/guardian's photo ID details.
Name
Address
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Vers 1.7 January 2021
Declaration - Person shooting on an Approved Range
or undertaking a Firearms Safety Training Course
P650
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NSW POLICE FORCE
FIREARMS REGISTRY
This form must be completed by all unlicensed persons before they can possess and use firearms in accordance with the
NSW Firearms Act 1996 and Regulation. Return the form to the club or range official or the instructor upon completion.
ABN 43 408 613 180
Driver Licence
or Passport No.
Male FemaleDate of Birth
MM YYYYDD
b) Been the subject of a Firearms Prohibition Order?
c) Within the last 10 years been convicted of an offence involving firearms, weapons, prohibited drugs,
robbery, violence, terrorism or an offence of a sexual nature?
d) Within the last 10 years been the subject of a Family Law or Domestic Violence Order or an
Apprehended Violence Order (other than an order that was revoked)?
e) Ever attempted suicide or self harm?
B. PERSONAL HISTORY - You MUST complete this section - Mark X in one box for each question
Have you in NSW or elsewhere;
f) In the past 12 months been treated or referred for treatment for alcoholism, drug dependence or
a mental illness within the meaning of the Mental Health Act 2007 or as a mentally disordered
person within the meaning of that Act?
a) Been refused or prohibited from holding a firearms licence or permit or had a firearms licence or
permit suspended, cancelled or revoked?
YES
NO
YES NO
NO
YES NO
YES
NOYES
NOYES
Photo ID Number
Type of
Photo ID
Previous / other known names - If you have been known by
another name, please provide details (Last Name, Given Names)
Phone
Number
YES NOg) Currently subject to a Good Behaviour Bond?
NOYES
h) Currently subject to an Interim Apprehended Violence Order?
PLEASE TURN OVER FOR DECLARATION AND CLUB CERTIFICATION
i) Currently suffering from any mental illness or other disorder that may prevent you from using a
YES NO
firearm safely?
IF YOU ANSWERED YES TO QUESTION (a) SPEAK DIRECTLY TO A CLUB REPRESENTATIVE
IF YOU ANSWERED YES TO QUESTIONS (b) - (i) YOU ARE INELIGIBLE TO PARTICIPATE IN SHOOTING ACTIVITIES
INVOLVING THE POSSESSION AND USE OF FIREARMS.
