Professional Documents
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ABN43408613 180
This fonn must be completed by all unlicensed persons beforc they can possess and use firearms in accordance with the NSW FireqrmsActl99Sand Regulation. Returnt{reformtothe club orrangeofficial ort{ie instructor upon completion.
A. PERSONAL DETAILS
Name Address
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Photo lD Number
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Photo lD
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ln this Section a minor (12 - 18 years) completes the details and the parenUlegal guardian must provide the photo lD.
B. PERSONAL HISTORY - You MUST complete this section - Mark an X in one box for each question
Have you in NSW or elsewhere;
revoked? Order?
safely?
YES
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NOK
b) Are you currently subject to a Good Behaviour Bond or lnterim Apprehended Violence
YEs
YES YES YES
Order?
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E
NoB
NOE
NOEI
d) Are you suffering fiom any mental illness or other disorder that may prevent you from using a firearm
e) Been convicted within the last l0 years of an offence involving: firearms orweapons; prohibited drugs;
robbery; violence or terrorism; or an offence of a sexual
nature?
Withinthelastl0yearsbeenthesubjectofafamilylaworDomesticViolenceOrderoranApprehended
Violence Order (other than an order which was revoked)?
IF YOU AHSWEREDYESTO ANYOFTHEABOVE
YES
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NoEl NOB
QUESTIOT{S,YOU ARE IIIEUGIBLETO PARTICIPATEII{ SHOOTIT{G ACTMTIES INVOLVINGTHE POSSESSIOI{ AI{D USE OF FIREAff|rS.
C. DECLARATION
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understand that it is a serious offence under the Fireorms Act l996to make a statement or provkCe information that I know i, f"1.. o, *isleading & I cerfiry that all the information contained in this dedaration is true and correct in every detail.
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agree to the NSW Police Force undertaking such enquiries provided in relatiotl to this application is true and correcl
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as are necessary
Applicants Signature
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-TO BE
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give consent for the person nomed in this Delaration (the Minor) to
ParenVGuardt"n
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IIOTE: The parenVlegal guardian must supply photographic proof of identity to the range/club official or firearms instructor. The range/club official or instructor must be satisfied that this requirement has been met.
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Date
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Approval No
Club/Range Approval No
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