Form Msp 77r-3-Authorization For Release Of Information To Purchase A Regulated Firearm


Maryland State Police
Authorization for Release of Information to Purchase a Regulated Firearm
Instructions: This form must be submitted with MSP 77R Part 1 and Part 2. The Application
number on Part 2 of the Application must be written in the spaces marked “Application #”.
Application #: ________________________
Applicant Information
Last Name: ______________________ First: _________________ Middle: ____________ Suffix: ____
Driver’s License ID #: _______________________ State: _______ Social Security #: ______________________
Street Address: ________________________________________________________________________________
Town/City: ________________________________________ State: _______ Zip Code: ____________________
Date of Birth: ___________________________ Race: ________________________ Sex: Male
I, ___________________________________________________________________________,
(First Name)
(Middle Name)
(Last Name)
authorize the Department of Health and Mental Hygiene, or any other similar agency or
department of another state, to disclose to the Department of State Police information limited to
whether I suffer from a mental disorder as defined in §10-101(f)(2) of the Health–General
Article and have a history of violent behavior against anyone; or whether I have been voluntarily
admitted for more than 30 consecutive days or involuntarily committed to a facility or institution
that provides treatment or services for individuals with mental disorders.
I acknowledge that this information will be used solely as part of the investigation required by
Title 5, Subtitle 1 of the Public Safety Article, Annotated Code of Maryland, to determine my
eligibility to possess a regulated firearm. In the event that my Application to purchase a
regulated firearm is disapproved, I acknowledge that this authorization and any information
obtained via this authorization may be used in any proceeding relating to the disapproval.
I further acknowledge that I may at any time, except to the extent that the Department of State
Police has already taken action in reliance on it, revoke this authorization by submitting a
request for revocation in writing. If not previously revoked, this authorization will terminate one
year after the date I sign this Application or upon notification to me of the disapproval of this
Application, whichever occurs first.
MSP 77R-3 (10/1/13)


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Parent category: Legal