Msp 77R 3 Form PDF Details

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Form NameMsp 77R 3 Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesmaryland 77r application, maryland state police 77r application, 77r maryland, form 77r

Form Preview Example

Maryland State Police

Authorization for Release of Information to Purchase a Regulated Firearm

Instructions: This form must be submitted with MSP 77R Part 1 and Part 2. The Application number on Part 2 of the Application must be written in the spaces marked “Application #”.

Application #: ________________________

Applicant Information

Last Name: ______________________ First: _________________ Middle: _____ _______ Suffix: ____

Driver’s License ID #: _______________________ State: _______ Social Security #: ______________________

Street Address: ________________________________________________________________________________

Town/City: ________________________________________ State: _______ Zip Code: ____________________

Date of Birth: ___________________________ Race: ________________________ Sex: Male Female

I, ___________________________________________________________________________,

(First Name)

(Middle Name)

(Last Name)

authorize the Department of Health and Mental Hygiene, or any other similar agency or department of another state, to disclose to the Department of State Police information limited to whether I suffer from a mental disorder as defined in §10-101(f)(2) of the HealthGeneral Article and have a history of violent behavior against anyone; or whether I have been voluntarily admitted for more than 30 consecutive days or involuntarily committed to a facility or institution that provides treatment or services for individuals with mental disorders.

I acknowledge that this information will be used solely as part of the investigation required by Title 5, Subtitle 1 of the Public Safety Article, Annotated Code of Maryland, to determine my eligibility to possess a regulated firearm. In the event that my Application to purchase a regulated firearm is disapproved, I acknowledge that this authorization and any information obtained via this authorization may be used in any proceeding relating to the disapproval.

I further acknowledge that I may at any time, except to the extent that the Department of State Police has already taken action in reliance on it, revoke this authorization by submitting a request for revocation in writing. If not previously revoked, this authorization will terminate one year after the date I sign this Application or upon notification to me of the disapproval of this Application, whichever occurs first.





MSP 77R-3 (10/1/13)

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portion of empty spaces in msp form 77r

Fill in the I further acknowledge that I may, Signature, Date, and MSP R section with the information requested by the platform.

part 2 to filling out msp form 77r

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