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i canity that I am the chief law en I o< cement officer ol the or sanitation named below having jurisdiction in the area ol residence o

(Name of Maker!

I have no infoimation indicating that the maker will ute the firearm or device described on this application lor other than lawful PMIPOMI I have no information that POSSESSION OF THE FIREARM OESCRIBEO IN ITEM 4 ON THE FRONT OF THIS FORM WOULD PLACE THE MAKER IN VIOLATION OF STATE OR LOCAL LAW.

(Signature and Till« ol Chief Law Enforcement Officer m IMPORTANT noie below) BY I See IMPORTANT note below» ______

I Signature and Title of Delegated Per »on I

IStreet Address)

I City, Sute, and ZIP Code)

IMPORTANT: The chief law en lor cement She'i'l lor the maker's county ot residence attorney or prosecutor having luntdiction in the maker'» ar Oirector. Bureau ol Alcohol. Tobacco and f irearmt, such 1 tu lign on behall ol the Chief ol Pol we, Sheriff, etc.. this fi olticie>'l n*me and lille. followed by the word "by" end 1*

'« city or town of residence, the ■nee; a State or local district 'tifkation it acceptable to the U S Attorney. II someone has specif« delegated author»?

nust be noted by printing the Chief's. Sheriff's, or other authorised ill signature and title ol the delegated person.

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