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

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

Female

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.

________________________________________________

_______________________

(Signature)

(Date)

MSP 77R-3 (10/1/13)

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