OMD No.

U.S. llcp11rlmc111or Justlrc
Burcnu of Alcohol, Tobucco, Firearms and Explosives

11-10-0020

Firearms Transaction Record
I run~foror\/Scl er•~
Trnnsuc1ion Serial
Number (I/any)

I G: ou muy not rccch c a llrcurm f pmhl led hy Federul or talc luw. The nformutlon you provide will be used to
determine whether you arc 1>mhlblled from receMng II firearm. Ccrt11ln vlolntlons of the Gun Control Act, 18 U.S.C. 92 I
cl. Se<),, are punl~hablll by up to IO years Imprisonment und/or up lo 11 $250,000 line.
Rc11d the Notices, Instr uctions, 11nd Dcllnlllons on this form. P rc1111re In orlglnnl only 111 the licensed premises ("/ke11Jed pre111l1e.1"
l11clude.1' bu.fi11tw.,· temporarily cm,ductedfrom a qualijj-/11,: ,:1111 show or event i11 the same State /11 which the /ice11sedpre111£5es L,·
/{}C'ated) unless the transucllon qunllflcs under IH U.S.C. 922(c). All entrfos must be hundwrl11en in Ink. " PLEASE PRINl:"
Section A - Must Uc Co mpleted Pcrsonnlly By Trnnsfcrcc/lluycr

I. fmnsfcrcc's/Buycr's Full Nn111e ((/legul 11n111e con/aim <111 in Ilia/ 011(1•, recon/ "JO" ,ifter the i11i11al. (f110 middle initial or name, rfford "NMN ".)
Lnst Nnmc (l11c/udi11g .wff,x (e.g .. J,; Sr. II. Ill))
First Name
Middle Name

2. Current Stutc of Residence and Address (U.S. Postal ubbreviatlons are acceptable. Cannol be a post office box.)
Number and Street Address
City
County

3. Pince of Birth
U.S. City and State

-OR-

I

Foreign Country

4. Height
Ft.

---

In.
8. Social Security Number (Optional, b111 will help prevent misidentification)
I 0.a. Ethnicity

5. Weight
(Lbs.)

6. Sex
Male
Female

0
O

ZIP Code

State

7. Birth Date
Month

I

/Year

Day

9. Unique Personal Identification Number (UPJN) if applicable (See
lnstrnctionsfor Question 9.)

10.b. Race (111 addition lo ethnicity, select one or more race in 10.b. Both IO.a. and 10.b. must be answered.)

O Hispanic or Latino
O American Indian or Alaska Native O Black or African American
O Not Hispanic or Latino O Asian
0 Native Hawaiian or Other Pacific Islander

□ White

11 . Answer the following questions by checking or marking 'yes" or "no" in the boxes to the right of the questions.
a. Are you tile actual transtereetbuyer ot the nrearm(s) hstca on thts form? warnmg: You are not the actual transrereetouyer tr you

Yes No

are acquiring the firearm(s) on behalf of another person. If you are not the actual transferee/buyer, the licensee cannot transfer
the firearm(s) to you. Exception: If you are picking up a repairedfirearm(s) for another person, you are not required to answer I I.a.

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and may proceed to q11estion I l .b. (See /nstrnctionsfor Question I I.a.)

b. 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? (See l11s1mc1ionsfor Q11estion 11.b.)
c.

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Have you ever been convicted in any court of a felony, or any other crime for which the judge could have imprisoned you for more
than one year, even if you received a shorter sentence including probation? (See Instructions for Question I I.e.)

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d. Are you a fugitive from justice? (See /11strnc1io11sfor Question 11.d.)
e.

f

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Are you an unlav. lul user ol, or aaatcted to, manJuaria or any depressant, stimulant, narcottc drug, or any other controlled substance?
Warning: The use or possession of marijuana remains unlawful under Federul law regardless of whether it has been legalized or
decriminalized for medicinal or recreational purposes In the state where you reside.

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Have you ever been adjudicated as a mental defective OR have you ever been committed to a mental institution? (See Instructions
for Question 11 f)

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g. Have you been discharged from the Armed Forces under d ishonorable conditions?
h. 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? (See Instructions for Question 11.h.)
Have you ever been convicted in any court of a misdemeanor crime of domestic violence? (See lnstn1ctions for Question 11.i.}

I.

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12.a. Country of Citizenship: (Check/List more than 011e, ifapplicable. Nahonals ofthe Umted States may check U.S.A.)

0

United States ofAmerica (U.S.A)

0

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Other Country/Countries (Specify) :

12.b.

Have you ever renounced your United States citizenship?

12.c.

Arc you an alien illegally or unlawfully in the United States?

12.d. I.

Are you an alien who has been admitted to the United States under a nonimmigrant visa? (See lnstmctions for Question 12.d.)

12.d.2.

Jf'·yes", do you fall within any of the exceptions stated in the instructions'?

0

NIA

y,.,

No

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13. If you are an alien, record your U.S.-Issued Alien or Admission number (AR#, USCJS#, or 194#):
Previous Editions Are Obsolete

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ATF Forni 4473 (5300.9)
Revised 0 ~ 20 I 6