MARYLAND STATE POLICE APPLICATION AND AFFIDAVIT TO PURCHASE A REGULATED FIREARM

PART 1 (Page 2 of 2)Application # ______________________

12. Are you the respondent against whom a current non ex parte civil protective order has been entered under 4-506 of the Family Law Article, or against whom an order for protection as defined in 4-508.1 of the Family Law Article has been issued by a court of another state or Native American tribe and is in effect?

O Yes O No O N/A

Initial: ________

13. Are you presently charged with a crime punishable by imprisonment for a term exceeding one year or dire you wanted by a law enforcement agency for the commission of a crime?

O Yes O No

Initial: ________

14. Are you a habitual drunkard? (Habitual drunkard means any person who has been found guilty of any three alcohol offenses, one of which occurred within the past year.)

O Yes O No

Initial: ________

15. Are you an addict or habitual user of any controlled dangerous substance? (Habitual user of a controlled dangerous substance means any person who has been found guilty of two controlled dangerous substance offenses, one of which occurred within the past 5 years.)

O Yes O No

Initial: ________

16. Have you ever been discharged from the armed forces of the United States under dishonorable conditions; or have you ever renounced your United States Citizenship; or are you illegally or unlawfully in the United States?

O Yes O No

Initial: ________

If a truthful answer to any of the above 16 questions is "yes, it is a violation of the law for you to purchase or possess a firearm. Providing a false answer to any of these questions is a crime and may result in imprisonment and/or a fine. (DO NOT PROCEED.)

17. Have you ever been voluntarily admitted for more than 30 consecutive days or involuntarily committed to a facility or institution that provides treatment or services forindividuals with mental disorders?

If no- continue to question #18.

If yes- It is a violation of law for you to purchase or possess a fireman unless you attach a certificate issued by the Department of Health and Mental Hygiene affirming your mental competence to possess a firearm. Do not continue the application without the certificate.

O Yes O No

Initial: ________

18. Have you ever been found not criminally responsible or incompetent to stand trial due to a mental disorder or disorders?

If no- continue to question #19.

If yes- It is a violation of law for you to purchase or possess a fireman unless you attach a certificate issued by the Department of Health and Mental Hygiene affirming your mental competence to possess a firearm. Do not continue the application without the certificate.

O Yes O No

Initial: ________

19. Do you 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 yourself or another? (Mental disorder includes a mental illness that so substantially impairs the mental or emotional functioning of an individual as to make care or treatment necessary or advisable for the welfare of the individual or for the safety of the person or property of another.)

If no- continue to question #20.

If yes- It is a violation of law for you to purchase or possess a fireman unless you attach a certificate issued by the Department of Health and Mental Hygiene affirming your mental competence to possess a firearm. Do not continue the application without the certificate.

O Yes O No

Initial: ________

20. Have you ever been under the protection of a guardian appointed by a court for a reason other than physical disability?

If no- continue to question #21.

If yes- It is a violation of law for you to purchase or possess a fireman unless you attach a certificate issued by the Department of Health and Mental Hygiene affirming your mental competence to possess a firearm. Do not continue the application without the certificate.

O Yes O No

Initial: ________

21. What is your country of citizenship? __________________________________ If you are not a citizen of the United States, what is your INS-issued alien number or admission number?

________________________________________

Initial: ________

22. If you are NOT a Designated Collector: Have you purchase a regulated firearm within the past 30 days?

If yes, give date: ______/______/__________.

O Yes O No O N/A

Initial: ________

23. If a regulated firearm is lost or stolen, the owner of the regulated firearms shall report the loss or theft to the local law enforcement agency within 72 hours after the owner first discovers the loss or theft.

The Owner Must Also Notify Any Subsequent Recipient of the Firearm of this Requirement.

Initial: ________

NOTICE: 7-Day Waiting Period. A dealer or other person may not sell, rent, transfer, or purchase a regulated firearm until after 7 days following the time a firearm application is forwarded to the Maryland State Police. For a secondary sale or transfer, the application must be forwarded by a dealer or a designated law enforcement agency.

Signature of Transferee / Voluntary Registrant and Transferor

(Sign upon completing Part 1 of this Application)

I certify under the penalty of perjury that the information contained in this Application is true and accurate. I understand that any false or omitted information can result in the disapproval of this Application and lead to my arrest.

Incomplete /Unreadable Applications Will Automatically Be Disapproved. No Exceptions

Transferee/Voluntary Registrant: _____________________________ Transferor/Dealer: ____________________________ Date: ____/____/_____

MSP 77R-1 (10/1/13)(Page 2 of 2)