ATF Form 5400.28: Explosives Employee Possessor Questionnaire

Enter the Federal Explosives Licensee or Permittee Name (1) and the Federal Explosives License or Permit Number (2) (If being added to an existing FEL/P).

Enter the Name of Employee Possessor (Last, First, Middle) (3), any Aliases (Include given, married, maiden names, etc.) (4) and the Position/Title (5).

List any given, married, and maiden names in Item 4 (e.g., “Mary Alice (Smith) Jones,” not “Mrs. John Jones.”). (If additional space is needed, attach a separate sheet. See Instruction 1.)

Enter the Social Security Number (Voluntary) (6), the Date of Birth (MM/DD/YYYY) (7) and the Place of Birth (City & State OR Foreign Country) (8).

Disclosure of the individual's SSN is voluntary.

Enter the Current Full Residential Address (9) and the Mailing Address (If different from residential address) (10).

Provide the Previous Address(es) (14) - (Please provide residential history and dates for the past five years. Use additional sheet(s) if necessary.)

Enter the Telephone Number (Including area code) (11), the E-mail Address (12) and the Driver's License or State ID Number (Include State of issuance) (13).

Mark Sex (15), and enter Height (16), Weight (lbs) (17), Eye Color (18) and Hair Color (19).

Mark Ethnicity (Hispanic or Latino, Yes or No) (20). For Race (21), check one or more boxes.

For the following questions, give full details on a separate sheet for all “Yes” answers. Answer Yes or No.

Mark Yes or No for 22. Have you ever been a Responsible Person or Employee Possessor for a Federal Explosives Licensee or Permittee? (If known, please include FEL/P Name and/or Number)

23. Will you be or are you an employee of the FEL/P listed in question 1?

24. Will you have actual or constructive possession of explosive materials in the course of your employment?

An EP is an individual who has actual or constructive possession of explosive materials during the course of his employment.

25. Have you ever been issued a letter of denial for your clearance to possess explosives by ATF?

26. Have you ever been granted Explosives Relief from Disability? If so, please attach a copy of the relief letter.

27. Are you under indictment or information in any court for a felony, or any other crime, for which the judge could imprison you for more than one year? Or are you a current member of the military who has been charged with violation(s) of the Uniform Code of Military Justice, and whose charge(s) have been referred to a general court-martial?

28. Have you ever been convicted in any court, including a military court, for a felony, 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?

29. Are you a fugitive from justice?

30. Are you an unlawful user of or addicted to marijuana, any depressant, stimulant, narcotic drug, and/or any other controlled substance? Warning: The use or possession of marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes by state law.

31. Have you ever been adjudicated as a mental defective or committed to a mental institution?

32. Have you been discharged from the Armed Forces under dishonorable conditions?

33. Country of Citizenship: (Check/List more than one, if applicable. Nationals of the United States may check U.S.A.) United States of America or Other Country/Countries (specify).

Mark Yes or No for 34. Have you ever renounced your United States citizenship? (18 U.S.C. § 842(i)(7))

35. Are you an alien who has been admitted to the United States for permanent residence? (18 U.S.C.§ 842(i)(5)(A))

36. Are you an alien who has been admitted to the United States under a nonimmigrant visa? (18 U.S.C. § 842(i)(5)(B))

37. If you are an alien, record your U.S.-Issued Alien or Admission Number (e.g., AR, USCIS, or I-94 number). Attach supporting documentation to this questionnaire. (Please note that an employment authorization card insufficient to qualify to serve as an EP.)

An alien in the United States means any person who is not a citizen or national of the United States.

For purposes of this form, aliens can be EPs if they are lawful permanent residents.

38. Under the penalties imposed by 18 U.S.C. §§ 842 and 1001, I declare that I have reviewed the answers on this form and examined any related documents submitted regarding this questionnaire (ATF Form 5400.28), and to the best of my knowledge and belief, they are true, correct, and complete.

This signature, when presented by a duly authorized representative of the U.S. Department of Justice, will constitute consent and authority for the appropriate U.S. Department of Justice representative to examine and obtain copies and abstracts of records, and to receive statements and information regarding my background.

Fill in Signature, Printed Name and Date under SIGN.

A copy of this form may be used for your renewal submission (See instruction 2 and 3). By signing Your Signature (For subsequent submission) and Date, you certify, under penalties of perjury, that your answers on this form are still true, accurate and complete.

If this form is being submitted after an FEL/P has been issued to add you as an EP, the completed form must be accompanied by a signed letter from the licensee or permittee requesting that you be added as an EP.

A Responsible Person (RP) must submit a signed written request along with a completed ATF Form 5400.28, granting permission to add a new EP to an existing FEL/P.

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.

If this form is being submitted for at least a second time, in relation to the same FEL/P renewal, the EP may follow Instruction 3 and submit the form to: ATF National Services Center, Federal Explosives Licensing Center, 244 Needy Road, Martinsburg, WV 25405.

You must complete and submit this form to your employer (applicant for federal explosives license/permit (FEL/P)). The employer will submit this form on your behalf to ATF for processing.