Atf Permit Form – Fill Out and Use This PDF

		OMB No. 1140-0070
U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives	Application for Explosives License or Permit
Section A (Must be completed by all applicants.) Please print all information in block letters.		FOR ATF USE ONLY

1.Name of Applicant (If partnership, include name of each partner)

2. Trade Name or Business Name, if any			3. Employer Identification Number (EIN) or Social
			Security Number (SSN) (Voluntary-see Privacy Act
			Information)							Attach 2" x 2" Photograph Here
										(See Instruction 8)
4. Name of County in Which	5a. Premises Address (No., Street, City, State, Zip Code)
Business is Located
5b. Mailing Address (If different from address in Item 5a.)
										NOTE: A completed FD-258 (Fingerprint
										Identification Card) must accompany this
										application. (See Instruction 8)
6. Location (If no street address listed in Item 5a, provide directions and					7. Telephone Number (Include Area Code)
distance from nearest post office or city limits)					Business	(	)
					Residence	(	)
					Emergency	(	)
					Fax	(	)
					E-Mail Address
8. Are you presently engaged in a business and/or operations for which a license or permit is required under 18 U.S.C., Chapter 40, Explosives?
(If yes, provide date business began.)		Yes/Date:								No

9. Is or will your business and/or operations be: (Check appropriate box)

10. Method of Payment (Check one)

	Check (Enclosed)	Cashier's Check or	Visa	Mastercard	American	Discover	Diners Club
		Money Order (Enclosed)			Express
	Credit/Debit Card Number (No dashes)			Name as Printed on the Credit/Debit Card		Expiration Date (Month & year)

Please Complete to Ensure Payment is Credited to the Correct Application:

I am Paying the Application Fee for the Following Person, Corporation, or Partnership:	Total Application Fees:

I Authorize ATF to Charge my Credit/Debit Card the Above Amount.

Signature of Cardholder

Date

Your credit/debit card will be charged the above stated amount upon receipt of your application. The charge will be reflected on your credit/debit card statement. In the event a license/permit is NOT issued, the above amount will be credited to the credit/debit card noted above.

ATF E-Form 5400.13/5400.16 Revised November 2018

Responsible Person(s) List

11.Provide information for each individual owner, partner, and all other responsible persons (See Definition 3) in the trade or business operations identified in section A, block 2. List all names used by each responsible person (i.e., nicknames, maiden name, name from previous marriage, etc.) (If additional space is needed use a separate sheet.)

			Social Security			Date of Birth		Country/
	Full Name	Position at	Number	Home Address and	Telephone		Place of Birth	Countries			Race
	(If the individual is an alien, also		(Voluntary - will	E-mail Address	Numbers	(Month/Day/		of Citizen-	Sex	Ethnicity
											(Mark all that apply)
	provide his/her U.S.-issued alien	Business	help prevent	(Include ZIP Code)	(Home/Work)	Year)	g	ship	i	j
											j
	number or admission number.)	b	misidentification)	d	e	(XX/XX/XXXX)		h
	a		c			f
										Are you	American Indian or
										Hispanic	Alaska Native
											Asian
										or
										Latino?	Black or African
											American
										Yes	Native Hawaiian or
											Other Pacific Islanders
										No	White
										Are you	American Indian or
										Hispanic	Alaska Native
										or	Asian
										Latino?	Black or African
											American
										Yes	Native Hawaiian or
											Other Pacific Islanders
										No
											White
										Are you	American Indian or
										Hispanic	Alaska Native
											Asian
										or
										Latino?	Black or African
											American
										Yes	Native Hawaiian or
											Other Pacific Islanders
										No	White
										Are you	American Indian or
										Hispanic	Alaska Native
											Asian
										or
										Latino?	Black or African
											American
										Yes	Native Hawaiian or
											Other Pacific Islanders
										No	White
										Are you	American Indian or
										Hispanic	Alaska Native
											Asian
										or
										Latino?	Black or African
											American
										Yes	Native Hawaiian or
											Other Pacific Islanders
										No	White

ATF E-Form 5400.13/5400.16 Revised November 2018

12. Application is made for an explosives license or permit under 18 U.S.C., Chapter 40, as an: (See definitions 5 through 9)

Explosives License					Fee	Renewal	Explosives Permit		Fee	Renewal
						Fee				Fee
Manufacturer (Check the types of explosives you plan to							User of Explosives (Check the types of explosives you plan to
manufacture:)							use:)
High Explosives			Low Explosives				High Explosives	Fireworks
Theatrical Flash Powders			Fireworks	$200		$100	Blasting Agents	Other (Specify)	$100	$50
Blasting Agents			Other (Specify)				Low Explosives
Importer (Check the types of explosives you plan to import:)							Limited Permit (Intrastate Only) (Check the types of
							explosives you plan to use:)
High Explosives	Fireworks						High Explosives	Fireworks
Blasting Agents	Other (Specify)			$200		$100	Blasting Agents	Other (Specify)	$25	$12
Low Explosives
							Low Explosives
Dealer (Check the types of explosives you plan to deal in:)
High Explosives			Low Explosives
Blasting Agents			Fireworks	$200		$100
Black Powder			Other (Specify)

			Total Fees
13.	Is a State or local license or permit required for explosive business and/or operations? (If yes, provide license/permit numbers; if applied for license/
	permit but not yet obtained, provide date of application.)	Yes/Numbers or Date			No
14.	Is the applicant or any person named in item 11: (ALL questions must be answered by checking the "YES" or "NO" box.) (Give full details on a Yes				No
	separate sheet for all "yes" answers in item 14.)

a.A fugitive from justice?

b.An unlawful user of, or addicted to, marijuana or any depressant, stimulant, or narcotic drug, or any other controlled substance?

c.Under indictment or information in any court for a felony, or any crime, for which the judge could imprison that person for more than one year? (An information is a formal accusation of a crime by a prosecutor.) (See Definition 1.)

d.An alien in the United States? (If "yes," attach an explanatory statement showing that the person is a lawful permanent resident or a lawful

nonimmigrant or refugee/asylee.) (See Definition 2 and Exception 2.)	Statement Attached.
If the individual is an alien, provide the U.S.-issued alien number or admission number in item 11.
e. Presently appealing a conviction of a crime punishable by imprisonment for a term exceeding one year? (If "yes," attach an explanatory
statement showing date of conviction, court in which convicted, and court in which appeal is pending.)		Statement Attached.
15. Has the applicant or any person named in item 11 EVER: (Give full details on a separate sheet for all "yes" answers in item 15.)			Yes No

a.Been convicted in any court of a felony, or any other crime, for which the judge could have imprisoned that person for more than one year, even if he or she received a shorter sentence, including probation? (See Definition 1 and Exception 1.)

b.Been adjudicated mentally defective (which includes having been adjudicated incompetent to manage his or her own affairs) or been committed to a mental institution?

c.Been discharged from the Armed Forces under dishonorable conditions?

d.Renounced his or her United States citizenship?

Section B (Must be completed)

16. Hours of Operation and/or Availability of Business Activity (Please provide at least one hour in which you may be contacted by ATF Personnel.)

Time	Sunday	Monday	Tuesday	Wednesday	Thursday		Friday	Saturday
Open
Close
17. Applicant's Business and/or Operation is Located in:
A Commercial Building			A Residence		Other (Specify)

ATF E-Form 5400.13/5400.16 Revised November 2018

18. Applicant's Business and/or Operations Premises are:

21. Do you Intend to Deal in Black Powder? Do You Have a Federal Firearms License? (If "yes," provide the Federal firearms license number)

Storage Facility Data

Section 842(j), 18 U.S.C., provides "It shall be unlawful for any person to store any explosive material in a manner not in conformity with regulations promulgated by the Attorney General." Before applying for a license or permit, the applicant must read and be familiar with the requirements as set forth in 27 CFR, Part 555, Subpart K - STORAGE. An application for a license will be denied if upon an investigation it is found that storage facilities are

inadequate.

22a. All of the applicant's storage facilities listed on the attached Explosives Storage Magazine Description Worksheet(s) and meet the minimum requirements as set forth in 27 CFR, Part 555, Subpart K - Storage. If "no" i.e., storage facilities do not meet minimum requirements) explain on separate sheet. (See Instruction 10.)

22b. Please indicate the total number of explosives storage magazine(s).

22c. If the applicant has no storage facilities, provide contingency plan for unexpected surplus explosive materials by completing Explosives Storage Magazine Description Worksheet Item J. (See Instruction 10.)

Section C - Certification (Must be completed by all applicants)

23.Under the penalties imposed by 18 U.S.C. 844, I certify that the answers are true, correct, and complete. I also certify that I am familiar with all published State laws and local ordinances relating to explosive materials for the location in which I intend to do business. In addition, if the application is for a Limited Permit, I certify that I will not receive explosive materials on more than 6 separate occasions during the 12-month period for which my limited permit is valid.

For Bureau of Alcohol, Tobacco, Firearms, and Explosives Use Only

ATF E-Form 5400.13/5400.16 Revised November 2018

Explosives Storage Magazine Description Worksheet

(Submit one for each magazine; you may photocopy for additional magazines)

Applicant name:

Magazine ID no:

State/local explosives magazine certificate number, if any:

Storage magazine address:

A.Type of magazine (e.g., permanent, mobile/portable, indoor/outdoor, building, igloo, tunnel, dugout, box, trailer, semitrailer, or other mobile magazine):

ATF Type: (Check one)	I	II	III	IV	V

B.Location of magazine and distance from licensed place of business and other magazine:

C.Distance to nearest storage magazine, regardless of ownership:

D.Describe terrain features, roads, structures, buildings, utilities, etc., that could be damaged if the contents of the magazine exploded:

E.Distance(s) between the magazine and the feature(s):

Indicate if magazine is:

Barricaded

Unbarricaded

Show distance in feet to:

Closest highway:

Closest inhabited bldg:

Closest passenger railway:

F. Materials, including thicknesses, used in construction of magazine:

Roof:

Top:

Walls:

Bottom:

Doors:

Floor:

G.

1.

Security, physical safeguards, safety equipment, and anti-theft measures:

2.

Locks (Check all that apply):

Three-point Lock

Mortise Locks

Padlocks

3.

If Padlocks:

Shackle Diameter:

No. of Tumblers:

Steel Hoods: Yes

No

Case-hardened: Yes

No

H. Dimensions and capacity of magazine:

Capacity (in pounds or number of detonators):

Height:

Length:

Width:

I. Explosives to be stored: Quantity or Weight

Class:

High

Low

Blasting Agents

Detonators

J.

1. Magazine is (Check one):

Owned

Borrowed

Leased

Rented

Contingency Plan

2.Owner of magazine if borrowed, leased, rented, or on contingency:

3.Address and phone number of owner:

K.Names and telephone numbers of persons who can open magazine for inspection:

L.Special conditions, such as difficulty accessing in winter, etc.:

M.A plat plan must be furnished, not necessarily to scale, which will indicate, at a minimum, (1) all buildings on the premises, and (2) all magazines

identified. with distances between the magazines, as well as the distances between magazines and inhabited buildings, public highways, and passenger railways.

Prepared by:

Date: