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10. Law Enforcement Certification (See instruction 2g)

I certify that I am the chief law enforcement officer of the organization named below having jurisdiction in the area of residence of

(Name of maker)

I have no information that the maker will use the firearm or device described on this application for other than lawful purposes. I have no information that Possession

of the firearm described in Item 4 on the front of this form would place the maker in Violation of State or Local Law.

(Printed name)

(Title and agency name)

(Signature of Chief Law Enforcement Officer)

(Street address, city, State and zip code)

(Telephone Number)

(Date)

By (if delegated authority to sign for the chief law enforcement official):

(Printed name)

(Title and agency name)

(Signature)

(Street address, city, State and zip code)

(Date)

(Telephone Number)

Maker’s Certification

A maker who is an individual must complete this Section.

11. Answer questions 11.a. through 11.j. Answer questions 13 through 16 if applicable. For any YES answer (other than for 11.i.), the applicant shall provide details

on a separate sheet. (See instructions 7c and definitions)

Yes

12. Photograph

a. Are you under indictment or information in any court for a felony, or any other crime, for which the judge

could imprison you for more than one year?

b. Have you ever been convicted in any court for a felony, or any other crime, for which the judge could

imprison you for than one year, even if you received a shorter sentence including probation?

c. Are you a fugitive from justice?

Affix

d. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any

Recent Photograph Here

other controlled substance?

(Approximately 2” x 2”)

(See instruction 2e)

e. Have you ever been adjudicated mentally defective (which includes a determination by a court, board,

commission, or other lawful authority that you are a danger to yourself or others or are incompetent to

manage your own affairs) OR have you ever been committed to a mental institution?

f. Have you been discharged from the Armed Forces under dishonorable conditions?

g. Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an

intimate partner or child of such partner?

h. Have you ever been convicted in any court of a misdemeanor crime of domestic violence?

i. Are you a United States citizen?

j. Have you ever renounced your United States citizenship?

If you answered “NO” to question 11.i., please answer questions 13, 14, 15 and 16.

13. Answer questions 13.a. through 13.b., and 14 by checking or marking “Yes or “No” or “NA” in the boxes to the right of the questions.

Yes

a. Are you an alien Illegally in the United States?

b. Are you an alien admitted to the United States under a nonimmigrant visa? * If the answer is “NO”, do not respond to question 14 and proceed to

questions 15 and 16.

14. If you are an alien admitted to the United States under a nonimmigrant visa, do you fall within any of the exceptions set forth in the instructions (see definition

2.u.)? If the answer is “YES”, a copy of the Documentation must be attached to the Application.

N/A

Yes

15. What is your country of Citizenship if other than the United States? (Specify Country)

16. If you are not a Citizen of the United States, what is your U.S.-issued alien number or admission number?

CERTIFICATION: Under penalties imposed by 26 U.S.C. 5861, I certify that the statements contained in this Certification, and any attached documents in

support thereof, are true and correct to the best of my knowledge and belief.

Signature of Maker

Date

ATF Form 1 (5320.1)

Revised June 2014