Fillable Form S.p. 634 - Certificate Of Eligibility

CLEAR FORM

STATE OF NEW JERSEY

CERTIFICATE OF ELIGIBILITY

(This form must be completed for each transfer of a Shotgun, Rifle, including black powder or BB Rifle)

Part 1: This section must be completed by the transferor (seller or giver) of the firearm.

Make of Firearm:____________________________________________ Action: __________________________________________

Pump, Lever, Semi-Automatic, Bolt etc.

Model of Firearm: _____________________________ Caliber or Gauge: ______________ Serial #:_________________________

Name of Transferor (or Dealer Employee): _________________________________________________________________________

Last

First

Dealer Name (if applicable): __________________________________ Dealer’s State License Number: _______________________

Address of Transferor: (Dealer: list your licensed location)

____________________________________________________________________________________________________________

Street

Town/City

State

Zip Code

Transferor’s Firearms I.D. Card Number:____________________________________ Date of Transfer: ________________________

Part 2: This section must be completed by the person receiving (receiver of) the firearm.

Name of Receiver: ___________________________________________________________ ________________________________

Last

First

Telephone Number

Address: ____________________________________________________________________________________________________

Street

Town/ City

State

Zip Code

Date of Birth: ____________________ Firearms Purchaser I.D. Number:________________________________________________

1) Have you ever been convicted of a crime that has not been expunged or sealed? .....................................................

Yes

2) Are you subject to any court order prohibiting you from possessing firearms?.........................................................

Yes

3) Are you subject to any court order issued pursuant to Domestic Violence?

NOTICE: If you have had a Final Restraining Order issued against you within the last two years, you must answer “Yes” and

are ineligible to possess a firearm. The period of ineligibility is two years from the date of issuance of the Final Restraining Order

or the date it was dismissed whichever is longer........................................................................................................

Yes

4) Have you ever been convicted of a disorderly persons offense or its equivalent, in any jurisdiction, involving an act of domestic

violence that involved the offense(s) of (1) Simple Assault (2) False Imprisonment (3) Lewdness (4) Criminal Trespass or

(5) Harassment that has not been expunged or sealed? ..............................................................................................

Yes

5) Are you an alcoholic? NOTE: A recovered alcoholic may answer no to this question..........................................

Yes

6) Are you dependent upon the use of any narcotic or other controlled dangerous substance? .....................................

Yes

7) Do you suffer from any physical defect or sickness which makes it unsafe for you to handle firearms?..................

Yes

8) Since the issuance of your firearms I.D. card, have you been confined for a mental disorder? .................................

Yes

9) Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts

of violence, either to overthrow the government of the United States or of this State, or to deny others of their rights under the

Constitution of either the United States or the State of New Jersey?.........................................................................

Yes

10) Are you a fugitive from justice? .................................................................................................................................

Yes

11) What is your State of residence? __________________

If other than NJ, this transfer must go through a licensed firearms dealer.

___________________________________________

Signature of Transferor

Signature of Receiver

Should you have any questions in completing this form, contact the Fire-

I hereby certify that the answers given on this form are complete, true

arms Investigation Unit, New Jersey State Police, P.O. Box 7068, West

and correct in every particular. I realize that if any of the foregoing an-

Trenton, NJ 08628-0068 (609) 882-2000 Ext. 2060 or 2061.

swers made by me are false, I am subject to punishment.