Form ATF F 3210.1 ATF F 3210.1 Application for Restoration of Firearms Privileges

0MB No. 1140-0002

U.S. Depurtment ur .Justice
Bureau ofAlcohol, Tobacco, Fircanns and Explosives

I.

Name (Last, First, Middle)

2.

llinhplnce (City & SUiit!)

<,.

rrcscnl Address (No., Sm,.,,. City, Stutt·, Zip Codt!)

8.

Description

J.

Application for Relief from Federal
Firearms Disabilities

Dale of llinh

4.

Aliases

5. Social Sccurily Number (Vi1h111111r,1)
7. Telephone Number

Wcighl
E1hmci1y

Race (C/r(•ck on.: or mon• lmx.:s)

D Hispimic or Latino
D
D Not Hispanic or La1ino D
9.

American Indian or i\laska Native
Asian

Hair

D
D

Eyes

□

Black or African American

White

Native Hawaiian or Other Pacific Islander

If you are not a ci1izen of 1he Uni led Stales, what is your INS-issued alien number or admission number?

IO. Residences During Pnst Ten Years (fll rn/11m11.i (bJ und (,·) .:nter the months wrd veurs uf 1-esi,11!11,·e.)
Address (Nu111bl!r, Stree/, Cily, State mrd Zip Code)
{a)

From

To
(cJ

(I>)

11. Employm.:nl Record (list prescrrt a11d prillr employt!rs mu/ show montlr mrd rrnr of cmpltll'mell/.)
Name and Address of Employer
Position
(u)
fb)

12. Co nviclions (If parda11ed for a cu111:ictim1 write "'yes" i11 co/11m11 (c) mrd auach u copv of thtt paHlo11.)
Spcci fie Crime
Nume and Locution of Coun
Sentence Rccci vcd
(/1)
(UI
(c•)

From

To
(di

(cl

Conviction Date

Pardoned

(d )

(I!}

13. Other Arrests
Charge
(u)

14. Probation Officer's Nan1c. Address and Tcleph<>nc Number

Dale und Plucc of Arrest
{{,)

Disposition
(c)

15. ramie Officer's Nnmc. Address and Telephone Number

ATF l'onn nrn.1

RcviscJ (

)

I(,. Characlcr References (Thre<· refi•r,•11c·c·., un· r•·q11ir<'d. Plcu.«· irrduJ,: ,1 wriflo:n .l'lt1l.:mo:nt fmm ,·11d1 11f J rcf,:rc•IK<'-', wh11 ur,: 1101 re"1t.:J fr, th.•
upplicu11t b:,, h/ooJ or m<1rrit1g.: "'"' hm·,· knmrn upplic<111t .filr <11 /cu.,r J ,l'<'Ur.1, r.•nm1111,:n,li11g 11,,: gr<1111ing of 1·eli,f)
Name and Address
(u}

Occupation

17. Ariplieant Duta (All qu,·stion., mu.,1 he un.,wer,•d In, a "}i.·s" or "No")

a. /\re you a fugitive from justice'!
b. Arc you on unlawful user of or addicted lo marijuana. or
any depressant, stimulant, or narcotic drug, or any other
controlled substance'!

c. Have you ever been conviclcd in any court of n folony, or
any other crime, for which the judge could have imprisoned
you for more than one year, even if you received a shorter
sentence, including probation'/ (({ ')'<'S," sec Additi,mal
/J1forma1io11 Requ,•st I.)

d. Arc you now on probation or purolc'?

e. Arc you under indictment or infom1ation in nny court for a

felony, or any other crime, for which the judge: could
imprison you for more than one year'! (An ill/ormution is u
furmul uccusatio11 of u crime by u pmsccul 258 (Flni:crprlnt ldentlfic11tlon Cartl) Must Accompany This ,\ppllcuflun.
Mall Appllcutlon Furm Tu:

llureuu or Alcohol, T11bucco, firearms 11nd Explosives
NCETll - Keller of l>lsabllltlH Program
C11rporal Road, Building 3750
Redstone Arn-n11l
Hunts,·llle, ,\ L 3SR9H

ATF F,mn 32IO.I

Ro,is�d t

I

U.S. Dep11rtment or .Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Authority for Release of Information

Authority for Release of Information
THIS SHEET MUST ACCOMPANY ALL COPIES OF ATF FORM 3210.1. APPLICATION FOR RELIEF FROM FEDERAL FIREARMS
DISABILITIES
1. Authority. The authority to solicit information is stated in ATF Form 3210.1, Application for Relief from Federal Firearms Disabilities. This
form is in compliance with the Privacy Act of 1974.
2. Purpose and Use. The information you supply by signing this release of information form will be used principally to aid in the completion
of a background investigation conducted by the Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), pursuant to 18
U.S.C. 925(c), in conjunction with your Application for Relief from Federal Firearms Disabilities.
J. Effects of Nondisclosure. Your signature on this Authority for Release of Information form is voluntary; however, your failure to complete
this form may mean that the required information cannot be obtained to complete your investigation, and may result in the termination of
your application.

N,nnc or Apphcunt (/ndudt! l,<1.>1, Fi1·Jt, ,md Mi,ldlt! Name u11d ,1/1 uli,is"s 11sc,I)

Dale or Birth

Pr.:!cnt Address (Numbl!r, Street, Cily. Stut,:. L•p Codt')

Telephone Number (illc/11de ,t,-i•a
Code)

This release. when presented l1y II duly authorized representative of tl1e Drp11rtment of ,lustke, will constitute my consent and authority to u11mlne
and uhtuln cnplH 11nd abstracts of records and to recel\'e statements and Information ngardlng my background. Spedflcally, I hereby authorize the
releue of tl1e following data or records to the Department of .Justice (ATF):
Employment Information, l\tlllt11ry Information/Records, Police 11nd Criminal Records, l\ledkal History
J\lcdlc11I Information Records
If fou Answered �1L's" 111 Items l7(h) or (f) on ATF Form 31/0,/, Complete the FolloH"in,: Sectio11.
Nnmc of Allcnding Physicinns, Alcohol or Dnig Abuse
Rcltabililation Centers, or r-.-lcntal Health Institutions

Signature of Applicant

Address
(l11cl11di11g City, State a11d Zip Code)

Date

Area Code and
Telephone Number

Speci al Agent/Investigator (Sign11111re)

Date

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