Applicant Certification

(Nam* of Transféra*) weapon tfsecribed on this ^ipBcitlw for fha (oBowinQ reaeon and my paaeeiilon of the device or weapon wouW be consistent w«ti public safety MS U.3.C. 122(b) (4) and 27 CPU 17SJM.

UNDER PENALTIES OF PERJURY. 1 declare that I have examined this appfcetion. and lo the be« of my knowledge and beBsf it is true. correct and complete, and that receipt and pnasasalon of the firearm described on this lorm win not place me in violation of the provisions of Chapter 44. TM* IS. U.S.C.; Chapter S3. Title 26, U.S.C.; or Tide VII of the Omnibus Crime Control and Safe Streets Act, as amended, or any piovidot» of Slate or tool law.

(Signature of Ttanefaree or official euthorteed to sign for firm)

». LAW ENFORCEMENT CERTIFICATION (See IMPORTANT note betowl

I certify that I am (ha chief taw enforcement officer of (he organization named below having juried«

Indicating that the transferee wil use the fire-

in item 4 of this form w

(Signature end TWe of Chief Urw Enter catrwnt Officer - Se* IMPORTANT nose below)

IMPORTANT: The chief law en I or cement officer is considered to be ihe Chief of Police lor the transleree's city or town of residenca, the Sheriff (or the trenefarea's county of reeidence: the Head of the State Police for the transferee's Stat* of r*sid*nc*, a State or local dietrict attorney or proeecutor having Jurisdiction in the transferee's area of residenca; or another person whoee certification is acceptable to the Director, Bureau of Alcohol. Tobacco and Fireerme. If aomeono hee specific delegated authority to sign on behalf of the Chief of PoBce, Sheriff, etc , (his fact must bo noted by printing ihe Chief's. Sheriff's, or other authorized officioCs neme and title, followed by the word "by" and the full signature and title ol the dais gated person

/ APPLICANT

rYM oa MUHT Ail INFORMATION IN BLACK Uli MOM NAM flXfNMM OTCUMAMS

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UGHATufft or rtnow rwossiwrie

I« PC ATP 0000

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