Please TYPE or PRINT neatly in BLACK INK using UPPERCASE letters.
1. FFL # (NINE numeric, ONE alpha, FIVE numeric) NOTE: 03 Licensees need not enroll:
_ - _ _ - _ _ _ - _ _ - _ _ - _ _ _ _ _ |
2.Code Word (Must be six to ten characters - NO PROFANITY)
|
3.Business Telephone Number
_ _ _ - _ _ _ - _ _ _ _
|
Name of FFL Licensee: (Name that appears on FFL License. If company name, place in LAST Name block and place overflow in FIRST and MI blocks-if necessary.)
4. Last Name
|
First Name
|
MI
|
Cadence (Jr., Sr., etc.)
|
5. Name of Licensee Business (Store Name):
|
6. Post Office Box or Street Address of Licensee Store Premise:
|
City
|
State
_ _ |
|
ZIP Code
_ _ _ _ _ - _ _ _ _ |
7. Point of Contact Person (If Different Than Item 4 Above): |
Last Name
|
First Name
|
MI
|
8. Point of Contact Phone Number
_ _ _ - _ _ _ - _ _ _ _
|
9. Business Fax Number:
_ _ _ - _ _ _ - _ _ _ _
|
(FBI NICS E- Check users only) FBI NICS E-Check User Complete This Section
Every FFL & employee wanting to use the FBI NICS E-Check must complete and submit, by mail, this entire form and provide the following additional information then access our web site at www.nicsezcheckfbi.gov and request a digital certificate:
10. Last Name
|
First Name
|
MI
|
Cadence (Jr., Sr., etc.)
|
11. Mother's Maiden Name (Last name only)
|
12. E-Mail Address |
Note: If there is a change in FFL management or ownership, the FBI NICS Operations Center must be notified and a new acknowledgment must be signed.
By executing this document and/or by the use of the above codeword, the FFL acknowledges understanding of its obligations and responsibilities under the NICS (as detailed in the Gun Control Act of 1968, as amended and the Responsibilities of a Federal Firearms Licensee (FFL) under the National Instant Criminal Background Check System, dated July 31, 1998) and intent to honor those obligations and responsibilities. Intending to be legally bound, I hereby execute this acknowledgment on behalf of the above-mentioned FFL and certify under penalty of perjury that I have full authority from the FFL to make a legally binding commitment on its behalf.
13. User/Applicant Signature
|
Date Executed |
14. FFL Witness
|
Date Executed |
FEDERAL FIREARMS LICENSEE (FFL) ENROLLMENT FORM ITEMS OMB NO. 1110-0026
- FFL Number - This is the 15-digit number assigned by the Bureau of Alcohol, Tobacco, Firearms and Explosives.
- Code Word - This is a code word of your choice to be used as a verification of identity when you contact the NICS Operation Center. The code word MUST be between 6 and 10 characters in length, and can include both numbers and letters. NO OBSCENE WORDS OR PHRASES PLEASE.
- Business Phone Number - Please write the complete business telephone number including area code.
- Name Of Federal Firearm Licensee - The name of the individual or corporation licensed by the Bureau of Alcohol, Tobacco, Firearms and Explosives to sell firearms. If the name is a corporation name, and additional space is required, you may use the First Name spaces.
- Name Of Licensee Business - Store name.
- Street Address - Please fill in the entire mailing address section, complete with city, state, and ZIP code.
- Point Of Contact Person/E-Check Applicant - This is the person the FBI will call first when contacting your store. It is only needed if different from the name of the licensee. This may be a store manager or other responsible individual chosen by the licensee to represent the licensee for NICS matters, including codeword changes, validation of the FBI NICS E-Check users, etc.
- Point Of Contact Phone Number - This is the telephone number the FBI will call first when contacting your store. It is only needed if different from the business phone number. Please include area code.
- Business Fax Number - Please write the complete telephone number including area code.
For FBI NICS E-Check Enrollment only
- NAME of FFL or Employee who will be accessing the FBI NICS E-Check - Every user of the FBI NICS E-Check must complete, sign, and mail in the enrollment form to the NICS Section as well as submitting a digital request on the Internet.
- Mother's Maiden Name (For E-Check Enrollment only) - Enter your mother's maiden name. This will be used to help identify users of E-Check should the need arise.
- E-Mail Address - If you provide your e-mail address you will be notified by e-mail when your digital certificate is ready for downloading otherwise you will be contacted by telephone.
- Signature - Under the authority of Brady Handgun Violence Prevention Act (Brady Act), 18 U.S.C. Chapter 44, as implemented by 28 C.F.R. Part 25, the FBI requires completion of this acknowledgment by all FFLs as a condition of being granted NICS inquiry privileges. The NICS has been established within the FBI's CJIS Division for the purpose of performing instant background checks on prospective firearm transferees. The primary purpose of this acknowledgment is to ensure that FFLs accessing and using the NICS understand and accept the attendant obligations and responsibilities. This acknowledgment will be used to identify and validate those FFLs who may be granted NICS inquiry privileges, to legally obligate the FFL to comply with these obligations and responsibilities, and to serve as evidence of an FFL's knowledge and acceptance of these obligations and responsibilities whenever such matters may be in issue. Completion of this acknowledgment by an FFL is voluntary, but an FFL that does not complete this acknowledgment will not be able to make a NICS inquiry. It is a criminal violation of federal law for an FFL to transfer a firearm to a non-FFL without making a NICS inquiry.
- FFL Witness - This is the signature of an individual witnessing the aforementioned signature.
- Date Executed - This is the date that the enrollment document was signed by each person.
A person is not required to respond to any collection of information unless it displays a currently valid OMB control number. The FBI has created the NICS Enrollment Form so that it is easily understood and requires the least possible burden on you to provide us with information. The reporting burden for collection of information on the NICS Enrollment Form is computed as: 1) learning about the documents, two minutes; 2) completing the NICS Enrollment Form, three minutes; 3) assembling, mailing, faxing or e-mailing the form to the FBI, three minutes for an estimated average of eight minutes per response. If you have comments regarding the accuracy of the estimates or suggestions for making this form simpler, you can write the Federal Bureau of Investigation, NICS Operations Center, P.O. Box 4278, Clarksburg, WV 26302-4278.
Privacy Act Statement : Pursuant to the Privacy Act of 1974, 5 U.S.C. 552a, we are providing the following information regarding this collection of information. The authority under which this information is being collected is the Brady Handgun Violence Prevention Act (Public Law 103-159) and title 28 CFR part 25. The principal purposes for which the information will be used are to enroll an FFL into the NICS, log a user onto the FBI NICS E-Check, and identify FFLs that submit NICS checks. The information collected may be shared with other government agencies for authorized purposes and with certain other persons and entities for other purposes as provided for in the most recently published routine uses for the NICS (Justice/FBI-018). The form requests both mandatory and optional information. If you omit mandatory information we may not be able to process your request.
NICs home | CJIS home |
