STATE OF NEW JERSEY
CERTIFICATE OF ELIGIBILITY
(This form must be completed for each transfer of a Shotgun, Rile, including black powder or BB Rile)
Part 1: This section must be completed by the transferor (seller or giver) of the irearm.
Make of Firearm:____________________________________________ Action: __________________________________________
Pump, Lever, Semi-Automatic, Bolt etc.
Model of Firearm: _____________________________ Caliber or Gauge: ______________ Serial #:_________________________
Name of Transferor (or Dealer Employee): _________________________________________________________________________
LastFirstMI
Dealer Name (if applicable): __________________________________ Dealer’s State License Number: _______________________
Address of Transferor: (Dealer: list your licensed location)
____________________________________________________________________________________________________________
StreetTown/CityState Zip Code
Transferor’s Firearms I.D. Card Number:____________________________________ Date of Transfer: ________________________
Part 2: This section must be completed by the person receiving (receiver of) the irearm.
Name of Receiver: ___________________________________________________________ |
________________________________ |
Last |
First |
MI |
Telephone Number |
Address: ____________________________________________________________________________________________________
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Street |
Town/ City |
State Zip Code |
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Date of Birth: ____________________ |
Firearms Purchaser I.D. Number:________________________________________________ |
1) |
Have you ever been convicted of a crime that has not been expunged or sealed? |
..................................................... q Yes |
q No |
2) |
Are you subject to any court order prohibiting you from possessing irearms? |
q Yes |
q No |
3) |
Are you subject to any court order issued pursuant to Domestic Violence? |
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NOTICE: If you have had a Final Restraining Order issued against you within the last two years, you must answer “Yes” and |
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are ineligible to possess a irearm. The period of ineligibility is two years from the date of issuance of the Final Restraining Order |
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or the date it was dismissed whichever is longer |
q Yes |
q No |
4)Have you ever been convicted of a disorderly persons offense or its equivalent, in any jurisdiction, involving an act of domestic violence that involved the offense(s) of (1) Simple Assault (2) False Imprisonment (3) Lewdness (4) Criminal Trespass or
(5) Harassment that has not been expunged or sealed? .............................................................................................. q Yes q No
5) |
Are you an alcoholic? NOTE: A recovered alcoholic may answer no to this question |
q Yes |
q No |
6) |
Are you dependent upon the use of any narcotic or other controlled dangerous substance? |
q Yes |
q No |
7) |
Do you suffer from any physical defect or sickness which makes it unsafe for you to handle irearms? |
q Yes |
q No |
8) |
Since the issuance of your irearms I.D. card, have you been conined for a mental disorder? |
q Yes |
q No |
9) |
Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts |
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of violence, either to overthrow the government of the United States or of this State, or to deny others of their rights under the |
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Constitution of either the United States or the State of New Jersey? |
q Yes |
q No |
10) |
Are you a fugitive from justice? |
q Yes |
q No |
11)What is your State of residence? __________________ If other than NJ, this transfer must go through a licensed irearms dealer.
___________________________________________ |
___________________________________________ |
Signature of Transferor |
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Signature of Receiver |
Should you have any questions in completing this form, contact the Fire- |
I hereby certify that the answers given on this form are complete, true |
arms Investigation Unit, New Jersey State Police, P.O. Box 7068, West |
and correct in every particular. I realize that if any of the foregoing an- |
Trenton, NJ 08628-0068 (609) 882-2000 Ext. 2060 or 2061. |
swers made by me are false, I am subject to punishment. |
Questions 1 - 10 must be answered “no” for the transfer of the irearm to proceed. |
Falsiication of this form is a crime of the third degree as provided |
A person who answers “yes” to any question is not eligible to receive a irearm. |
in NJS 2C:39-10c |
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White copy is to be retained by the transferor pursuant to N.J.S.A. 2C:58-3b. |
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Yellow copy is to be retained by the receiver. |
S.P. 634 (Rev. 04/05) |
If internet form, make and sign two copies. |
