Dealer'S Record Of Sale Of Firearm Worksheet - California Page 3

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State of California - Department of Justice
DEALER'S RECORD OF SALE
CFD NUMBER:
OF FIREARM
-
WORKSHEET
DROS NO. ASSIGNED:
TRANSACTION INFORMATION
DELIVERY
TRANSMISSION
TIME:
TIME:
DATE:
DATE:
FIREARM TYPE:
PAWN/
TRANSACTION TYPE:
If long gun
TRANSACTION
CURIO/ RELIC/
PRIVATE
CONSIGN-
PEACE
transaction, enter the
OLYMPIC/
EXEMPT FROM
LOAN
PARTY
HANDGUN
DEALER
OFFICER
MENT
YES
number of firearms:
GUN SHOW
(cert-list
OTHER
THE 1-
TRANSFER
(cert-list
SALE
RETURN
exempt)
EXEMPT/
(cert-list
TRANSACTION?
NO
HANDGUN-PER-
exempt)
LONG GUN(S)
(cert-list
(cert-list
exempt)
30-DAY LIMIT
exempt)
exempt)
WAITING PERIOD EXEMPTIONS
PURCHASER CLAIMS THE FOLLOWING WAITING PERIOD EXEMPTION PURSUANT TO 12078 PC (if applicable):
COLLECTOR STATUS
SPECIAL WEAPONS PERMIT
CA FIREARMS DEALER
PEACE OFFICER
(Valid for Curio/Relics Only)
Enter type of permit and number:
Enter CFD number:
STATUS
Enter COE Number:
(Does not include license to carry a
(Must have agency letter)
concealed handgun)
REVOLVER / PISTOL INFORMATION
(One form per
MAKE (As Stamped on Handgun) (Colt, S&W, etc)
MODEL (647, Redhawk, etc)
CALIBER(S)
SERIAL NUMBER
OTHER NUMBER (If Different from Serial Number)
HANDGUN TYPE:
REVOLVER
SEMI-AUTO
DERRINGER
OTHER
SINGLESHOT
HANDGUN COLOR:
BARREL LENGTH
HANDGUN ORIGIN (USA, Italy, etc)
SILVER/NICKEL/
BLUE STEEL
OTHER
STAINLESS
COMMENTS
FRAME
NEW
YES
NO
YES
NO
HANDGUN?
ONLY?
PURCHASER INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
SUFFIX
ALIAS FIRST NAME
ALIAS MIDDLE NAME
ALIAS LAST NAME
ALIAS SUFFIX
STREET ADDRESS
ZIP CODE
One of the following forms of identification is required to legally purchase fireams in California: California Driver's License (CDL), California ID (CID) card issued by the DMV, or Military ID (MIL) for active duty
military accompanied by permanent duty station orders indicating that the purchaser is stationed in California.
ID NUMBER
ID SOURCE
ID TYPE (Circle One)
IF NO, ENTER AR# OR
YES
US
I-94# and COUNTRY OF
CDL
CID
MIL
CITIZEN?
NO
CITIZENSHIP
TELEPHONE NUMBER
DATE OF BIRTH
PLACE OF BIRTH
RACE
(
)
MO
DAY
YR
SEX
EYES
HEIGHT
WEIGHT
HSC NUMBER OR EXEMPTION CODE (Handguns Only)
HAIR
HAS PURCHASER EVER BEEN CONVICTED OF A FELONY OR OF AN OFFENSE SPECIFIED IN PENAL CODE SECTION 12021.1 OR 12001.6; OR CONVICTED OF
YES
NO
ASSAULT, BATTERY, OR OTHER MISDEMEANOR OFFENSE SPECIFIED IN PENAL CODE SECTION 12021(c)(1) IN THE LAST 10 YEARS?
IS PURCHASER A DANGER/THREAT TO SELF OR OTHERS PURSUANT TO WELFARE AND INSTITUTIONS CODE (WIC) SECTION 8100, OR A PERSON WHO HAS BEEN
YES
NO
ADMITTED TO A MENTAL HEALTH FACILITY AS A DANGER TO SELF OR OTHERS PURSUANT TO WIC SECTION 5150, 5151, AND/OR 5152 WITHIN THE PAST FIVE YEARS?
HAS PURCHASER EVER BEEN ADJUDICATED BY A COURT TO BE A DANGER TO OTHERS, FOUND NOT GUILTY BY REASON OF INSANITY, FOUND
YES
NO
INCOMPETENT TO STAND TRIAL, OR PLACED UNDER A CONSERVATORSHIP, PURSUANT TO WELFARE AND INSTITUTIONS CODE SECTION 8103?
IS PURCHASER CURRENTLY THE SUBJECT OF ANY RESTRAINING ORDER PURSUANT TO FAMILY CODE SECTION 6380?
YES
NO
SIGNATURE OF PURCHASER
By signing this document, I hereby certify under the penalty of
perjury that the information provided is true and correct
PRIVATE PARTY TRANSFER (SELLER INFORMATION)
FIRST NAME
SUFFIX
MIDDLE NAME
LAST NAME
STREET ADDRESS
ZIP CODE
ID TYPE (Circle One)
ID NUMBER
CDL
CID
MIL
ID SOURCE
PLACE OF BIRTH
TELEPHONE NUMBER
IF NO, ENTER AR# OR
YES
US
(
)
I-94# and COUNTRY OF
CITIZEN?
NO
CITIZENSHIP
DATE OF BIRTH
RACE
SEX
SIGNATURE OF SELLER
By signing this document, I hereby certify under the penalty of perjury that the information provided is true and correct
MO
DAY
YR
DEALER INFORMATION
FIREARM SAFETY DEVICE DESCRIPTION AND/OR COMMENTS
DEALER TELEPHONE NUMBER
(
)
SALESPERSON'S PRINTED NAME & COE NUMBER (IF ISSUED)
SIGNATURE OF SALESPERSON
By signing this document, I hereby certify under the penalty of perjury that the information provided is true and correct
FALSIFICATION OF INFORMATION ON THIS FORM IS A MISDEMEANOR (PENAL CODE 12076)
5/2004

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