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NSW POLICE FORCE. FIREARMS REGISTRY


undenaking a Firearms SafetyTraining Course

P650

Declaration - Person shooting on an Approved Range or

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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DateorBirth
Type

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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;

a) Been refused or prohibited from holding


suspended, cancelled or

firearms licence or permit or had

firearms licence or permit

revoked? Order?
safely?

YES

fI

NOK

b) Are you currently subject to a Good Behaviour Bond or lnterim Apprehended Violence

YEs
YES YES YES

c) Been the subject of a Firearms Prohibition

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Violence Order (other than an order which was revoked)?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

to establish that the information I have

Applicants Signature

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-TO BE
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give consent for the person nomed in this Delaration (the Minor) to

in shooting activities involving the possession and ure of firearms.

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.

E. CERTIFICATION BY CLUB/RAI{GE OFFICIAL OR II{STRUCTOR - OFFICIAL/II{STRUCTOR USEONLY

Theabovenamepersonis: Authorisedtoshoot [l t_t


Signature
Club/Range Official or lnstructor Name Club Name

t{otauthorisedtoshoot f
Date

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lnstructor
Approval No
Club/Range Approval No

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