Personal Firearms Eligibility Check Application
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1
2S
C
TATE OF
ALIFORNIA
D
J
EPARTMENT OF
USTICE
BUREAU OF FIREARMS
P.O. Box 820200, Sacramento, CA 94203-0200
PERSONAL FIREARMS ELIGIBILITY CHECK APPLICATION
(PC 12077.5)
See Reverse for Instructions, Fees and Notary Acknowledgment
This Application Must Be Notarized by a Licensed California Notary Public
Name:
Last
Suffix (e.g.Jr., Sr.)
First
Middle
Alias(es):
Female
Male
Date of Birth:
California DL or ID#:
(Copy must accompany application)
Height:
Weight:
Eye Color:
Hair Color:
Race:
Telephone #:
U.S. Citizen: Yes
No
If no, you must provide your Alien Registration# or I-94#:
(Copy must accompany application)
Mailing Address:
City
State
Zip
Street Address
Physical Address:
(If Different)
City
State
Zip
Street Address
No person or agency may require or request an-
If the applicant for a firearms eligibility check intends
other person to obtain a firearms eligibility check
to purchase, transfer, or receive a firearm through a
or notification of firearms eligibility pursuant to
licensed dealer as required by law, a Dealer Record
Section 12077.5 of the Penal Code. A violation
of Sale (DROS) waiting period and background
check are both required. This is not a DROS.
of these provisions is a misdemeanor.
This check is for informational purposes and is
intended to assist applicants in ascertaining their
eligibility to possess and/or purchase firearms.
Any findings from this check will not result in the
applicant being arrested or prosecuted for pro-
viding false information for the purposes of com-
pleting a Dealer Record of Sale or a federal form
4473 (Firearms purchase/transfer application).
I declare under penalty of perjury (Sections 118 et seq., and 672 PC) that all statements made by me on this application are true and
complete. I expressly authorize DOJ to perform firearms eligibility checks of all relevant state and federal databases, including the
National Instant Criminal Background Check System. I also understand that if I currently possess/own firearms and the results of this
check reveal that I am ineligible to lawfully either possess or purchase firearms, I must relinquish any and all firearms in my possession.
Date:
Signature of Applicant:
(Must be Notarized on Reverse)
FOR DOJ USE ONLY
Date Received:
PFEC #:
Eligible:
Date Paid:
Ineligible:
Date Processed:
Complete Submission:
Eligible to Possess but not Purchase:
Processed by:
Incomplete Submission:
NTN #:
Determination Could not be made:
BOF 116 (Rev. 04/2009)
Continued on Reverse
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