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
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.
3. Middle Name
4. Name Suffix, if any (e.g.,
sr., Jr., III)
16. Federal explosives license/permit number for explosives business/
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
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
Alaskan Native
Native Hawaiian or Other
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
imprisoned you for more than one year, even if you
10. Sex (Check one box)
received a shorter sentence, including probation?
(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
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
*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)
ATF Form 5400.28
Revised January 2010


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