Federal Bureau of Investigation National Instant Crimina

Federal Bureau of Investigation
OMB NO. 1110-0026
National Instant Criminal Background Check System (NICS)
Federal Firearms Licensee (FFL) Enrollment / E-Check Enrollment
Please TYPE or PRINT neatly in BLACK INK using UPPERCASE letters.
1. FFL NUMBER Note: 03 Licensees need not enroll:
_

_

_

_

_

2. CODE WORD (Must be six to ten characters - NO PROFANITY)

3. BUSINESS PHONE NUMBER

_

_

NAME OF FFL: (Name that appears on FFL License. If company name, place
in LAST Name block and place overflow in FIRST and MI blocks-if necessary.)
4. LAST NAME

FIRST NAME

MI

CADENCE

5. NAME OF LICENSEE BUSINESS (STORE NAME):

6. POST OFFICE BOX OR STREET ADDRESS OF LICENSEE STORE PREMISE:

CITY

STATE

ZIP CODE

7. POINT OF CONTACT PERSON (If different than Item 4 above):
LAST NAME

FIRST NAME

8. POINT OF CONTACT PHONE NUMBER:

(FBI NICS E-Check users only)

MI

CADENCE

9. BUSINESS FAX NUMBER (optional):

-

-

-

FBI NICS E-Check Users Complete this Section

Every FFL & employee wanting to use the FBI NICS E-Check must complete and submit, by mail, this entire form and provide
the following additional information then access our web site at www.nicsezcheckfbi.gov and request a digital certificate:

10. LAST NAME

FIRST NAME

MI

CADENCE

11. MOTHER'S MAIDEN NAME (Last name only)
12. E-MAIL ADDRESS:

Note: If there is a change in FFL ownership, the FBI NICS Section must be notified and a new acknowledgment must be signed.
By executing this document and/or by the use of the above code word, the FFL acknowledges understanding of its obligations and
responsibilities under the NICS (as detailed in the Gun Control Act of 1968, as amended and the Responsibilities of a Federal Firearms
Licensee (FFL) under the National Instant Criminal Background Check System, dated October 7, 2002) and intent to honor those
obligations and responsibilities. Intending to be legally bound, I hereby execute this acknowledgment on behalf of the above-mentioned
FFL and certify under penalty of perjury that I have full authority from the FFL to make a legally binding commitment on its behalf.

13. User/Applicant Signature:

Date executed:

14. FFL Witness:

Date executed:

FEDERAL FIREARMS LICENSEE (FFL) ENROLLMENT FORM ITEMS

OMB NO. 1110-0026

1. FFL NUMBER - This is the 15 digit number assigned by the Bureau of Alcohol, Tobacco,
Firearms and Explosives.
2. CODE WORD - This is a code word of your choice to be used as a verification of identity when you
contact the NICS Section. The code word MUST be between 6 and 10 characters in length, and can
include both numbers and letters. NO OBSCENE WORDS OR PHRASES PLEASE.
3. BUSINESS PHONE NUMBER - Please write the complete business telephone number including area
code.
4. NAME OF FEDERAL FIREARM LICENSEE - The name of the individual or corporation license
by the Bureau of Alcohol, Tobacco, Firearms and Explosives to sell firearms. If the name is a
corporation name, and
additional space is required, you may use the First Name spaces.
5. NAME OF LICENSEE BUSINESS - Store name.
6. STREET ADDRESS - Please fill in the entire mailing address section - complete with city, state, and
zip code.
7. POINT OF CONTACT PERSON/FBI NICS E-CHECK APPLICANT - This is the person the FBI
will call first when contacting your store. It is only needed if different from the name of the licensee.
This may be a store manager or other responsible individual chosen by the licensee to represent the
licensee for NICS matters, including codeword changes, validation of the FBI NICS E-Check users, etc.
8. POINT OF CONTACT PHONE NUMBER - This is the telephone number the FBI will call first
when contacting your store. It is only needed if different from the business phone number. Please
include area code.
9. BUSINESS FAX NUMBER (optional)- Please fill in the complete number including area code.
(FBI NICS E-Check users only)
For FBI NICS E-Check Enrollment only.
10. NAME of FFL or Employee who will be accessing the FBI NICS E-Check - Every user of the FBI
NICS E-Check must complete, sign, and mail in the enrollment form to the NICS Section as well as
submitting a digital request on the internet.

11. MOTHER'S MAIDEN NAME (last name only) - Enter your mother's maiden name. This will be
used to help identify users of the FBI NICS E-Check should the need arise.
12. E-MAIL ADDRESS - If you provide your e-mail address you will be notified by e-mail when your
digital certificate is ready for downloading otherwise you will be contacted by telephone.
13. SIGNATURE - Under the authority of Brady Handgun Violence Prevention Act (Brady Act),
18 U.S.C. Chapter 44, as implemented by 28 C.F.R. Part 25, the FBI requires completion of this
acknowledgment by all FFLs as a condition of being granted NICS inquiry privileges. The NICS has been
established within the FBI=s Criminal Justice Information Services Division (CJIS) of the FBI for the
purpose of performing instant background checks on prospective firearm transferees. The primary purpose
of this acknowledgment is to ensure that FFLs accessing and using the NICS understand and accept the
attendant obligations and responsibilities. This acknowledgment will be used to identify and validate those
FFLs who may be granted NICS inquiry privileges, to legally obligate the FFL to comply with these
obligations and responsibilities, and as evidence of an FFL=s knowledge and acceptance of these obligations
and responsibilities whenever such matters may be in issue. Completion of this acknowledgment by an FFL
is voluntary, but an FFL, which does not complete this acknowledgment, will not be able to make a NICS
inquiry. It is a criminal violation of federal law for an FFL to transfer a firearm to a non-FFL without
making a NICS inquiry.
14. FFL WITNESS - This is the signature of an individual witnessing the aforementioned signature.
DATE EXECUTED - This is the date that the enrollment document was signed by each person.
A person is not required to respond to any collection of information unless it displays a currently valid OMB control number. The FBI
has created the NICS Enrollment Form so that it is easily understood and requires the least possible burden on you to provide us with
information. The reporting burden for collection of information on the NICS Enrollment Form is computed as: 1) learning about the
documents, 2 minutes; 2) completing the NICS Enrollment Form, 3 minutes; 3) assembling, mailing (to enroll in the FBI NICS E-Check
the enrollment form must be mailed), faxing or e-mailing the form to the FBI, 3 minutes for an estimated average of 8 minutes per
response. If you have comments regarding the accuracy of the estimates, or suggestions for making this form simpler, you can write the
Federal Bureau of Investigation, NICS Section, P. O. Box 4278, Clarksburg, West Virginia 26302-4278.
Privacy Act Statement: Pursuant to the Privacy Act of 1974, 5 U.S.C. 552a, we are providing the following information regarding this
collection of information. The authority under which this information is being collected is the Brady Handgun Violence Prevention Act
(Public Law 103-159) and title 28 CFR part 25. The principal purposes for which the information will be used are to enroll an FFL into
the NICS, log a user onto the FBI NICS E-Check, and identify FFLs that submit NICS checks. The information collected may be shared
with other government agencies for authorized purposes and with certain other persons and entities for other purposes as provided for in
the most recently published routine uses for the NICS (Justice/FBI-018). The form requests both mandatory and optional information. If
you omit mandatory information we may not be able to process your request.