Form ATF F 5400.28 ATF F 5400.28 Employee Possessor Questionnaire

OMB No. 1140-0072

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Employee Possessor Questionnaire

For ATF Use Only
Who needs to complete this form? This questionnaire MUST be completed by EACH employee possessor
of a Federal explosives licensee or permittee or applicant, unless otherwise provided. (See reverse for
RDS KEY:
definition of employee possessor.)
Employee Possessor Information and Certification
Print the Requested Information in Block Letters.

Explosives Applicant Business or Operations Name
14. Name and address of explosives business or operations at which you
are an employee possessor.

1. Last Name
2. First Name

15. Your position in the explosives business or operations.

3. Middle Name

4. Name Suffix, if any (e.g.,
Sr., Jr., II)

6. Social Security Number (Voluntary, will help prevent misidentification)

17a. List All Countries of Citizenship.

7. Place of Birth (City and State - or - City and Foreign Country)

If you indicated above you are a United States citizen, skip to question 18.
17b. What is your U.S.-issued alien number or admission number?

8. Date of Birth (Month/Day/Year)

The following questions must be answered with a “YES” or
“NO”. (See the “Note” at the bottom of the page.)

Hispanic or Latino

Yes

19. Are you an unlawful user of, or addicted to, marijuana or
any depressant, stimulant, or narcotic drug, or any other
controlled substance?

No

9b. Race (Check one or more boxes)
American Indian or Alaskan Native

Black or African American
Asian

White

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Native Hawaiian or Other Pacific Islander
10. Sex (check one box)
Female

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11. Home Telephone Number (Include area code)

12. Work Telephone Number (Include area code and extension)

13a. Street Address
13b. Apt. Number

Yes or
No

18. Are you a fugitive from justice?

9a. Ethnicity

Male

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5. Other Names Used - Including Maiden Name

16. Federal explosives license/permit number for explosives business/
operations.

Home Address

20. Have you ever been convicted in any court of a felony, or
any other crime, for which the judge could have imprisoned
you for more than one year, even if your received a shorter
sentence, including probation?
21. Are you under indictment or information in any court for a
felony, or any crime, for which the judge could imprison you
for more than one year? (An information is a formal accusation
of a crime by a prosecutor. See Definition 1.)
22. Have you ever been adjudicated mentally defective
(which includes having been adjudicated incompetent to
manage your own affairs) or have you ever been committed
to a mental institution?
23. Have you ever been discharged from the Armed Forces
under dishonorable conditions?

13c. City

24. Have you ever renounced your United States citizenship?
13d. State - or - Province, Foreign Country

25. Are you an alien in the United States? If “YES” attach an
explanatory statement if you are a lawful permanent resident.
(Generally, if you are an alien [except for a lawful permanent
resident alien], you cannot possess explosive materials.)

13e. Zip Code/Postal Code

Statement attached.
Under the penalties imposed by Federal law, I,
questionnaire are true, accurate and complete.
Your Signature

(Print Your Full Name)

, certify under the penalty of perjury that the answers on this
Date

*Note: A copy of this form may be used for your renewal submission. See instruction #2 and #3. I certify, under penalties of perjury, that my answers on
this form are still true, accurate and complete.
Your Signature (For second submission)
Date
ATF Form 5400. 28
Revised February 2013

Definitions

Instructions
1. Who must fill out and complete this form? EACH employee possessor, as
defined below, MUST personally complete this questionnaire from and certify
that the answers are true, accurate, and complete. This form is not require to
be completed by Employee Possessors whose sole responsibility is transporting
explosives in commerce.
2. To whom do I submit this form? You must complete and submit this form to
your employer (applicant for license/permit). The employer will submit this
form, along with the applicant, to ATF. If this form is being submitted
AFTER a license or permit has been issued in order to ADD you as an employee
possessor, then the form number must be accompanied by a signed letter from the
licensee or permittee requesting that you be added as an employee possessor. If
this form is being submitted for at least a second time, in relation to the same
license/permit renewal, the employee possessor may follow instruction 3 below
and the form should be sent to: ATF, Federal Explosives Licensing Center, 244
Needy Road, Martinsburg, WV 25405.
3. Resubmission of form upon 3-year renewal of license/permit. The person
completing the form may choose to resubmit a photocopy of their original ATF
Form 5400.28 provided the information has not changed. You must certify
that all the answers are still true, accurate and complete by signing and dating
the form.

2. Employee Possessor. An employee possessor is an individual who has actual or
constructive possession of explosive materials during the course of his
employment. Actual possession exists when a person is in immediate possession
or control of explosive materials (e.g., an employee who physically handles
explosives materials as part of the production process; or an employee, such as a
blaster, who actually uses explosives materials). Constructive possession exists
when an employee lacks direct physical control over explosive materials, but
exercises dominion and control over the explosive materials, either directly or
indirectly through others (e.g., an employee at a construction site who keeps
keys for magazines in which explosives materials are stored, or who directs the
use of explosive materials by other employees; or an employee transporting
explosive materials from a licensee to a purchaser).
3. Alien. An alien in the United States means any person who is not a citizen or
national of the United States.
Exceptions
1. A person who has been convicted of a felony, or any other crime, for which the
judge could have imprisoned the person for more than one year, is not prohibited
from shipping, transporting, possessing, or receiving explosives if: (1) the
conviction was properly invalidated by a court on the basis that the conviction
was unconstitutional; (2) in the case of a Federal conviction, the person received
a Presidental pardon; or (3) ATF granted relief from Federal explosives disabilities
under 18 U.S.C. § 845(b), 27 CFR 555.142.

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4. Why is this form required? 18 U.S.C., Chapter 40, was amended by the Safe
Explosives Act of 2002 (the Act). The Act made it unlawful for certain persons
to ship, transport, receive, or possess explosives materials. The Act also made it
unlawful to distribute explosive materials to certain persons. Information you
provide on this form will allow ATF to determine whether you, an employee
possessor in the explosives business or operations, are prohibited from shipping,
transporting, receiving, or possessing explosive materials. 18 U.S.C. § 842(d), (i).

1. Under Indictment or Information or Convicted in Any Court. An indictment,
information, or conviction in any Federal, State, or local court.

5. Should documentation be attached to clarify a response to a question or
item? Providing additional documentation to clarify a response to a specific
question or item on the front of this form could help prevent a delay in processing
your Employer Possessor Questionnaire. Please ensure that your name is on any
attached document(s). In addition, if your employer is renewing a Federal
explosives license or permit, ensure that the employer’s current license or permit
number is on any attached documents.

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6. How do I obtain additional forms? The form can be downloaded from ATF’s
website in Adobe PDF format at www.atf.gov/forms/index.htm. The form can
be ordered using ATF’s Online Distribution Center Order Form at
www.atf.gov/dcof/index.htm. The form can also be ordered by calling ATF’s
Distribution Center at (301) 583-4696.

D

7. What do I do if I am prohibited from possessing explosives as indicated
above? If you are prohibited from possessing explosives, you may request
relief from your Federal explosives disability by filing an ATF Form 5400.29,
Application for Restoration of Explosives Privileges. This form can be down
loaded from ATF’s website at www.atf.gov/forms/index.htm or may be obtained
by calling (202) 648-7110. Please be advised that you cannot possess explosives
until such time that relief from Federal explosives disabilities may be granted.
For example, if you are a nonimmigrant alien, you should answer “yes” to
question 25, and you are prohibited from possessing explosives. You may file a
relief application, but you cannot possess explosives until such time that ATF may
grant you relief.
8. Need assistance in completing the form? Please review information online
concerning this form at www.atf.gov, contact the ATF Explosives Licensing
Center at (304) 616-4400, or contact your local ATF office.
ATF Form 5400.28 is used to determine the eligibility of the employee possessor to
possess explosives materials. Under Federal explosives laws it is unlawful for
certain prohibited persons to possess explosives. See 18 U.S.C. § 842(d) and (i).
18 U.S.C. § 845 (a)(1) provides that these prohibitions do not apply to any
“aspects of transportation of explosives materials via railroad, water, highway, or air
that pertain to safety, including security, and are regulated by the United States
Department of Transportation or the Department of Homeland Security.” The
Department of Transportation and the Transportation Security Adminstration have
exercised their regulatory authority concerning employee qualifications to
transport explosive materials. Accordingly, ATF does not have to determine the
eligibility to possess explosives of Employee Possessors who fall within this
exception.

2. For purposes of this form, aliens can be employee possessors if they are lawful
permanent residents. 18 U.S.C. § 842(d)(7); (i)(5).
Privacy Act Information

The following information is provided pursuant to Section 3 of the Privacy Act of
1974, 5 U.S.C. § 552a(e)(3):
1. Authority. Solicitation of this information is made pursuant to 18 U.S.C. § § 842,
843. Disclosure of this information by the employee possessor is mandatory if
the employee possessor wishes to possess explosives.
2. Purpose. To determine the eligibility of the employee possessor to possess
explosvies materials.

3. Routine uses. The information will be used by ATF to make determinations set
forth in paragraph 2. In addition, information may be disclosed to other Federal,
State, foreign, and local law enforcement and regulatory agency personnel to
verify information on the employee possessor questionnaire and to aid in the
performance of their duties with respect to the regulation of explosives unless
such disclosure is prohibited by law. Finally, the information may be disclosed to
members of the public in order to verify the information on the questionnaire
when such disclosure is not prohibited by law.
4. Effects of not supplying the requested information. Failure to supply complete
information will delay processing and may cause denial of the application.
5. Disclosure of social security number. Disclosure of the individual’s social
security number is voluntary. Under 18 U.S.C. § § 842(f), 843, and Executive
Order 9397, November 22, 1943, ATF has the authority to solicit an individual’s
social security number. The number may be used to verify the individual’s identity.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this
information collection is to determine the eligibility of the employee possessor to engage in
certain operations. The information requested is required to obtain or retain a benefit and is
mandatory by statute. 18 U.S.C. § 843.
The estimated average burden associated with this collection is 20 minutes per respondent,
depending on individual circumstances. Comments concerning the accuracy of this burden
estimate and suggestions for reducing this burden should be addressed to Report Management
Officer, Resource Management Staff, Bureau of Alcohol, Tobacco, Firearms and Explosives,
Washington, DC 20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number.
ATF Form 5400. 28
Revised February 2013