Form UnNumbered National Instant Criminal Background Check System (NICS)

Federal Bureau of Investigation
National Instant Criminal Background Check System (NICS)
Federal Firearms Licensee (FFL) Enrollment/NICS E-Check Enrollment Form

OMB NO. 1110-0026

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
-

-

4. NAME OF FFL: (Name that appears on FFL License. If company name, print on LAST NAME line and write overflow on FIRST and MI lines if necessary.)
LAST NAME (LICENSEE NAME)

FIRST NAME

MI

CADENCE

5. NAME OF LICENSEE BUSINESS (TRADE/BUSINESS NAME):

6. MAILING ADDRESS:

CITY

STATE

ZIP CODE
-

7. PHYSICAL ADDRESS:

CITY

STATE

ZIP CODE
-

8. E-MAIL ADDRESS:

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

FIRST NAME

MI

10. POINT OF CONTACT PHONE NUMBER:
-

CADENCE

11. BUSINESS FAX NUMBER (optional):

-

-

-

***********************************************FBI NICS E-Check Users Complete this Section************************************************
Every FFL wanting to use the FBI NICS E-Check must complete and submit by fax, e-mail, or mail this entire form and provide the following additional
information (12 and 13 below). A Username and Password will be e-mailed to the address provided in block #13.
12. LAST NAME

13. FFL DATE OF BIRTH (MM/DD/YYYY)

FIRST NAME

NO

17. E-MAIL ADDRESS:

CADENCE

14. FFL MOTHER’S MAIDEN NAME

15. DOES THE FFL OPERATE IN A POINT OF CONTACT STATE?
YES

MI

16. IF YES, PLEASE INITIAL TO ACKNOWLEDGE USE OF FBI NICS SYSTEM
FOR AUTHORIZED PURPOSES ONLY

OMB NO. 1110-0026
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 using 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) 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.
Please be sure to read the NICS E-Check Subscribers Agreement before signing this document.
18. User/Applicant Signature:

20a. Date executed: ________________________________________

19. FFL Witness: _________________________________________________________

20b. Date executed: ________________________________________

FEDERAL FIREARMS LICENSEE (FFL) ENROLLMENT FORM ITEMS
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 licensed 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 – Trade/Business name.
6. MAILING ADDRESS – Please fill in the entire mailing address section – complete with city, state, and zip code.
7. PHYSICAL ADDRESS – Please fill in the entire physical address section – complete with city, state, and zip code.
8. E-MAIL ADDRESS – You may receive notifications and messages from the NICS Section via e-mail.
9. 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.
10. 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.
11. BUSINESS FAX NUMBER (optional) – Please fill in the complete number including area code.
(FBI NICS E-Check users only)
12. NAME OF FFL EMPLOYEE WHO WILL BE ACCESSING THE FBI NICS E-CHECK – This employee or owner will be the administrative user and the only one who can add
additional users as necessary. When adding additional users, you may assign them the user role you deem necessary. The enrollment form can be faxed to (888) 550-6427, e-mailed to
, or mailed to:
NICS Customer Service Triage and Actions Team
Federal Bureau of Investigation
Criminal Justice Information Services (CJIS)
1000 Custer Hollow Road
Clarksburg, West Virginia 26306.
13. FFL DATE OF BIRTH – The Date of Birth of the FFL completing this form (MM/DD/YYYY) to be used for security enhancements.
14. FFL MOTHER’S MAIDEN NAME – Last name of FFL’s Mother to be used for security enhancements.
15. DOES THE FFL OPERATE IN A POINT OF CONTACT STATE? – In a full POC state, the FFL contacts the state agency(ies) serving as an intermediary between the FFL and
NICS prior to the proposed transfer of a firearm to a non-licensed person for all mandated types of firearms. In partial POC states, FFLs contact the state POC for handgun checks
and the FBI for long guns.
16. IF YES, PLEASE INITIAL TO ACKNOWLEDGE USE OF FBI NICS SYSTEM FOR AUTHORIZED PURPOSES ONLY? – Initial to indicate you will use the NICS
In the manner defined by ATF and the FBI.
17. E-MAIL ADDRESS – You must provide an e-mail address. A Username and Password will be e-mailed to the e-mail address provided in this block. You may also receive
notifications and messages from the NICS Section via e-mail.
Please read – NICS E-Check Subscriber’s Agreement before signing this document.
18. SIGNATURE – Under the authority of Brady Handgun Violence Prevention Act of 1993 (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 CJIS Division 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 who 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.
19. FFL WITNESS – This is the signature of an individual witnessing the signature.
20a and 20b. 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, faxing or e-mailing the form to the FBI, 3 minutes for an estimated
average of 8 minutes per response. To submit comments regarding the accuracy of the estimates, to provide suggestions for making this form simpler, or to enroll by providing this form, you
can submit it to the NICS Section by fax at (888) 550-6427, by e-mail to , or by mail to:
NICS Customer Service Triage and Actions Team
Federal Bureau of Investigation
Criminal Justice Information Services (CJIS)
1000 Custer Hollow Road
Clarksburg, West Virginia 26306.

Privacy Act Statement:
Authority: The FBI is collecting the information on this form under the authority of the Brady Handgun Violence Prevention Act of 1993 (Public Law 103-159) and 28 CFR Part 25.
Principal Purpose: 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 form requests both mandatory and optional information. If you omit mandatory information, we may not be able to process your request.
Routine Uses: Your information may be disclosed pursuant to your consent and may be disclosed without your consent as permitted by 28 CFR Part 25 and applicable routine uses as set forth
in the System of Records Notice for the NICS, DOJ/FBI-018, 84 FR 54175 (Oct. 31, 2019). Routine uses include, but are not limited to, disclosures to ATF and local, state, tribal, and territorial
criminal justice agencies to facilitate NICS checks and for investigative and other authorized purposes.