Application For A Possession And Acquisition Licence Under The Firearms Act (For Individuals Aged 18 And Over) - Canada Page 6

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For Administrative Use
F
INFORMATION ABOUT FORMER CONJUGAL PARTNER
FORMER CONJUGAL PARTNER (See Information Sheet)
Provide information about your former conjugal partners. This includes any person, other than the person named in Box 18, with whom you have lived in a
conjugal relationship within the last two (2) years. If you need more space, list the information on a separate sheet of paper.
19. a) Last name of former spouse, common-law or other conjugal partner
b) First name
c) Date of birth (Y / M / D)
I declare that I do not know the current address and/or telephone number of my former spouse, common-law or other conjugal partner.
d) Street / Rural route / PO Box number
e) Apt. / Unit
f) City
g) Province / Territory
h) Country
i) Postal code
If the signature of your former spouse, common-law or other conjugal partner is not provided,
the Chief Firearms Officer has a duty to notify them of your application.
IF YOU HAVE ANY SAFETY CONCERNS ABOUT THIS APPLICATION, PLEASE CALL 1 800 731-4000.
j) Signature of former spouse, common-law partner or other conjugal partner
k) Date (Y / M / D)
l) Telephone number and time when he/she may be contacted
day
Extension
evening
(
)
-
G
SAFETY TRAINING CERTIFICATION (see Information Sheet)
20. a) Have you passed the Canadian Firearms Safety Course test?
Date (Year)
Province
No
Yes
If YES
Proof attached
b) Have you passed the Canadian Restricted Firearms Safety Course test?
Date (Year)
Province
No
Yes
If YES
Proof attached
c) Have you been certified by the Chief Firearms Officer as meeting the safety training requirements OR have you successfully completed a course
approved by the Attorney General of Manitoba or Quebec prior to 1995?
No
Yes
If YES, specify
Proof attached
H
REFERENCES
A reference is anyone who has known you for at least three (3) years and is at least 18 years old. However, he or she CANNOT BE your current conjugal
partner.
FIRST REFERENCE
21. a) Reference's last name
b) First name
c) Telephone number and time when he/she may be contacted
Extension
day
evening
(
)
-
d) Street / Rural route / PO Box number
e) Apt. / Unit
f) City
g) Province / Territory
h) Country
i) Postal code
IF YOU HAVE ANY SAFETY CONCERNS ABOUT THIS APPLICATION, PLEASE CALL 1 800 731-4000.
I declare that I have known the applicant for three (3) years or more. I have read the information supplied by the applicant on this application.
To the best of my knowledge and belief, I find it to be accurate and I know of no reason why, in the interest of safety of the applicant or any other
person, the applicant should not be given a licence to possess and acquire firearms.
Reference's signature
Date (Y / M / D)
Page 3 of 4
RCMP GRC 5592 E-W (2008/05/17) V5
CAFC 921

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