Revised March 2023
"WARNING:IT IS AN OFFENCE TO KNOWINGLY MAKE A FALSE DECLARATION ON THIS APPLICATION AND THIS MAY RESULT IN THE DENIAL AND/OR REVOCATION OF
YOUR APPLICATION AND/OR AUTHORISATION.
`
FIREARM LICENSING AUTHORITY
Application for Firearm User’s Permit
To Be Completed in BLOCK CAPITALS
Section A
Photograph of Applicant
Name: (Last Name, First Name, Middle Name) Mr. Mrs. Ms. Other
Please state:
Other names: (Nickname, alias, pet name)
Tax Registration No.: (TRN)
Date of Birth:
Age
Gender: Male Female
Marital Status:
Married Divorced Single
Place and Parish of Birth: (Hospital/Clinic/Home)
Nationality:
Current Address of Residence:
Mobile Number:
Home Number:
Work/Business Number:(Including Ext.)
Name and Address of Current Business/Employer:
Occupation:
Email Address: (MUST BE WRITTEN IN BLOCK CAPTIALS)
NEXT OF KIN INFORMATION
Last Name:
First Name:
Middle Name:
Relationship to Applicant:
Email address: (BLOCK CAPITALS)
Gender: Male
Female
Home Telephone No.
Mobile Telephone No.
Work/Business No.
Referees (Must not be the person who wrote the recommendation
Name – Last Name, First Name, Middle Name Mr.Mrs.Ms.
Occupation
Email
Home Telephone No.
Mobile No.
Business Telephone
No.(including extension)
Name – Last Name, First Name, Middle Name Mr.Mrs.Ms.
Occupation
Email
Home Telephone No.
Mobile No.
Business Telephone
No.(including extension)
State the details of the firearm for which the Firearm User’s Permit Provisional application is being made:
Firearm Make:
1.
Firearm Model:
Firearm Type:
Firearm Calibre:
Firearm Serial Number:
2.
3.
Have you ever applied for a Firearm Authorisation? Yes No
If Yes, what was the result?
FLA-216
Revised March 2023
"WARNING:IT IS AN OFFENCE TO KNOWINGLY MAKE A FALSE DECLARATION ON THIS APPLICATION AND THIS MAY RESULT IN THE DENIAL AND/OR REVOCATION OF
YOUR APPLICATION AND/OR AUTHORISATION.
Has any Firearm Authorisation previously issued to you been revoked, cancelled, suspended, surrendered? YES NO
If yes, state reason: __________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________
Has any previous Firearm issued to you been seized, lost or stolen? YES NO Not Applicable
If yes, give details:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Have you ever been deported from a foreign country? Yes No
If yes, give details: _______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
Are you domiciled or ordinarily a resident in Jamaica, (2 consecutive years) immediately preceding this application?
YES NO
I certify that the information provided on this application is true to the best of my knowledge, information
and belief.
Applicant's Signature Date
Section B -To be completed by Primary Holder
Name:(Last Name, First Name, Middle Name)
TRN:
Mobile Number:
Home Number:
Work/Business Number:
Email Address (IN BLOCK CAPITALS)
Current Address of Residence:
Name and Address of Present Business/Employer:
Occupation:
Licence Card No:
Licence Fee Certificate No.:
Date of Last Renewal:
Expiration Date of Licence Fee Cert.:
Firearm Make:
1.
Firearm Model:
Firearm Type:
Firearm Calibre:
Firearm Serial No.:
2.
3.
Have you ever been arrested/charged/convicted of an offence? YES NO
If yes, give details:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
___________________________________________________
Revised March 2023
"WARNING:IT IS AN OFFENCE TO KNOWINGLY MAKE A FALSE DECLARATION ON THIS APPLICATION AND THIS MAY RESULT IN THE DENIAL AND/OR REVOCATION OF
YOUR APPLICATION AND/OR AUTHORISATION.
FOR OFFICIAL USE ONLY
Date of Interview:
Method of submission:
Fees paid:
Payment receipt number:
Name of Interviewing Officer:
Signature of Interviewing Officer:
Name of Supervisor:
Signature of Supervisor:
Have you ever suffered from any mental health issues? YES NO
If yes, give details:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
___________________________________________________
Have you ever engaged in alcohol, drugs or substance abuse? YES NO
Have you ever been detained/convicted or charged with domestic violence?
If yes, give details:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
___________________________________________________
(Please read and indicate your agreement to each statement by ticking the boxes)
I consent to be fingerprinted and consent that such prints may be used to facilitate background
security checks.
I am aware that this application may be discarded should I fail to complete the processes as required by the
Authority.
Declaration of Truth
I certify that the information provided on this application is true to the best of my knowledge,
information and belief.
Primary Holder's Signature: Date:
