Atf Form 5400.28 - Employee Possessor Questionnaire - U.s. Department Of Justice, Bureau Of Alcohol, Tobacco, Firearms And Explosives

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U.S. Department of Justice

OMB No. 1140-0072

Bureau of Alcohol, Tobacco, Firearms and Explosives

Employee Possessor Questionnaire

Who needs to complete this form? This questionnaire MUST be completed by EACH employee possessor

For ATF Use Only

of a Federal explosives licensee or permittee or applicant, unless otherwise provided. (See reverse for

RDS KEY:

definition of employee possessor.)

Employee Possessor Information and Certification

Print the Requested Information in Block Letters.

Explosives Applicant Business or Operations Name

1. Last Name

14. Name and address of explosives business or operations at which

you are an employee possessor.

Pyro Shows Inc., 115 North 1st Street, P.O. Box 1776, Lafollette TN 37766

2. First Name

15. Your position in the explosives business or operations.

Pyrotechnician

3. Middle Name

4. Name Suffix, if any (e.g.,

sr., Jr., III)

16. Federal explosives license/permit number for explosives business/

operations.

1-TN-013-24-8G-12205 & 1-TN-013-20-8G-12206

**Expires 7/1/2018**

5. Other Names Used - Including Maiden Name

17a. List All Countries of Citizenship?

6. Social Security Number (Voluntary, will help prevent misidentification)

If you indicated above you are a United States citizen, skip to question 18.

7. Place of Birth (City and State - or - City and Foreign Country)

17b. What is your U.S.-issued alien number or admission number?

The following questions must be answered with a "YES" or

Yes

8. Date of Birth (Month/Day/Year)

"NO". (See the "Note" at the bottom of the page.)

18. Are you a fugitive from justice?

9. Race/Ethnicity (Check one or more boxes)

19. Are you an unlawful user of, or addicted to, marijuana or any

American Indian or

depressant, stimulant, or narcotic drug, or any other controlled

Hispanic

Alaskan Native

substance?

Native Hawaiian or Other

Asian

Pacific Islander

20. Have you ever been convicted in any court of a felony,

or any other crime, for which the judge could have

Black or African American

White

imprisoned you for more than one year, even if you

10. Sex (Check one box)

received a shorter sentence, including probation?

Male

Female

(See Definition 1, Exception 1.)

21. Are you under indictment or information in any court for a

11. Home Telephone Number (Include area code)

felony, or any crime, for which the judge could imprison

you for more than one year? (An information is a formal

12. Work Telephone Number (Include area code and extension)

accusation of a crime by a prosecutor. See Definition 1.)

22. Have you ever been adjudicated mentally defective (which

includes having been adjudicated incompetent to manage

Home Address

your own affairs) or have you ever been committed to a

13a. Street Address

mental institution?

23. Have you ever been discharged from the Armed Forces under

dishonorable conditions?

13b. Apt. Number

13c. City

24. Have you ever renounced your United States citizenship?

25. Are you an alien in the United States? If "YES," attach an

explanatory statement showing that you are a lawful

13d. State - or - Province, Foreign Country

permanent resident. (See Definition 3, Exception 2.)

(Generally, if you are an alien [except for a lawful

13e. Zip Code / Postal Code

permanent resident alien], you cannot possess explosive

materials.)

Statement Attached.

Under the penalties imposed by Federal law, I,

, certify under the penalty of perjury that the answers on

(Print Your Full Name)

this questionaire are true, accurate and complete.

Your Signature

Date

*Note: A copy of this form may be used for your renewal submission. See instruction #2 and #3. I certify, under penalties of perjury, that my answers on

form are true, accurate and complete.

Your Signature (For second submission)

Date

ATF Form 5400.28

Revised January 2010