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 Health–General 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.
________________________________________________ |
_______________________ |
(Signature) |
(Date) |
