Firearms and Explosives Office Form FIREARM REGISTRATION APPLICATION FORM (For Renewal of Class A Light Weapon/s) No. 4 (Revision_October 2022) LS TYPE OF LICENSE: TYPE 3 CTYPE 4 [TYPES OTHER LICENSE/S: Sports Shooter Antique Firearm Collector Gun Collector ten — Day Tear PERSONAL INFORMATION DATE: [ L Last Name First Name/s Middle Name Qualifier: Citizenship E-Mail Address Gatlnhectne Heaton Gg ttt Date of Birth CLC Vcr) Gender: a_] FL] Mobile Number Tin PD) PP TeD TT Remi Landline Number we CITT) Qualifications Dsusressman Cl Protessional Private Empoyee ected Ocal_CI Govt, ofa Diet Govt employe D.Gont Employee CI PNPIAFRIONer LEAS Cl Oters: Di ReserveaAeP (Rot PNPIAFPIOIer LEAS Firearm Residence Unit NoJBldg ‘StreetBrgy CCityiMunicipality Province Region Postal Code Firearm Information Dealer's Name [=e CERTIFICATION AND UNDERTAKING. | hereby certify that, pursuant to the provisions of Republic Act 10591, all statements provided herein are true and correct. Further, I ceriy that | have not been convicted of any crime involving moral turpitude, nor have | been convicted or am currently an accused in a pending criminal case for a crime that is punishable with a penalty of more than two (2) years, Above indicated firearms are for my personal use. Any misdeclaration/fraud stated in this application and the attached documentary requirements shall be a basis for the cancellation of my license and the revocation of the registration’s of my frearmn/s and its/their eventual confiscation without prejudice to the fling of criminal and/or civil charges against me. Signature above Printed Name SUBSCRIBED AND SWORN to before me this _ day of. his/her competent evidence of identity issued by on Sones of 30 NOTARY PUBLIC. 20___applicant exhibited to me ‘bearing ID No.