Form ATF F 3210.1 ATF F 3210.1 Application for Restoration of Firearms Privileges

OMB No. 1140-0002 (xx/xx/xxxx)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

1.

Name (Last, First, Middle)

2.

Birthplace (City & State)

6.

Present Address (No., Street, City, State, Zip Code)

8.

Description

Race

9.

3.

Sex

Date of Birth

Application for Restoration of Firearms
Privileges
4.

Aliases

Height

Weight

5.

Social Security Number (Voluntary)

7.

Telephone Number

Hair

Eyes

If you are not a citizen of the United States, what is your INS-issued alien number or admission number?

10. Residences During Past Ten Years (In columns (b) and (c) enter the months and years of residence.)
Address (Number, Street, City, State and Zip Code)
(a)

From
(b)

To
(c)

From
(c)

To
(d)

11. Employment Record (List present and prior employers and show month and year of employment.)
Name and Address of Employer
(a)

Position
(b)

12. Convictions (If pardoned for a conviction, write “yes” in column (e) and attach a copy of the pardon.)
Specific Crime
(a)

Name and Location of Court
(b)

Sentence Received
(c)

Conviction Date
(d)

Pardoned
(e)

13. Other Arrests
Charge
(a)

Date and Place of Arrest
(b)

14. Probation Officer’s Name, Address and Telephone Number

Disposition
(c)

15. Parole Officer’s Name, Address and Telephone Number

16. Character References (Three references are required. Please include a written statement from each of 3 references, who are not related to the
applicant by blood or marriage and have known applicant for at least 3 years, recommending the granting of relief.)
Name and Address
(a)

Occupation
(b)

Telephone Number
(c)

ATF Form 3210.1
Revised July 2003

17. Applicant Data (All questions must be answered by a “Yes” or “No”)
Yes
Yes
No
h. Have you served on active duty in the armed Forces? (If
a. Are you a fugitive from justice?
“yes” check Branch and complete following)
b. Are you an unlawful user of or addicted to marijuana, or
any depressant, stimulant, or narcotic drug, or any other
Army
Navy
Marines
Air
Coast
controlled substance?
Force
Guard
Service Serial Number
Date Entered Active Duty
c. Have you ever been convicted in any court of a felony, or
any other crime, for which the judge could have imprisoned
you for more than one year, even if you received a shorter
sentence, including probation? (If “yes,” see Additional
Information Request 1.)

Kind of Discharge

Date of Discharge
Yes

d. Are you now on probation or parole?
e. Are you under indictment or information in any court for a
felony, or any other crime, for which the judge could
imprison you for more than one year? (An information is a
formal accusation of a crime by a prosecutor.) (If “yes,”
see Additional Information Request 2.)
f. Have you ever been adjudicated mentally defective (which
includes having been adjudicated incompetent to manage
your own affairs) or have you been committed to a mental
institution? (If “yes,” see Additional Information Request
3.)

No

No

i. Are you subject to a court order restraining you from
harassing, stalking, or threatening your child or an intimate
partner or child of such partner? (If “yes,” see Additional
Information Request 5.)
j. Have you been convicted in any court of a misdemeanor
crime of domestic violence? (If “yes,” see Additional Information Request 6.)
k. Have you ever renounced your United States citizenship?
(If “yes,” see Additional Information Request 7.)
l. Are you an alien in the United States? (If “yes,” see
Additional Information Request 8.)
m. Have you ever applied for a federal firearms license or a
federal explosives license or Permit? (If “yes” show date
and with whom filed.)

g. Have you ever been discharged from the armed forces
under dishonorable conditions? (If “yes,” see Additional
Information Request 4.)
18. COMPLETE THIS ITEM ONLY IF APPLICANT WAS EVER ISSUED A FEDERAL FIREARMS LICENSE OR A FEDERAL EXPLOSIVES LICENSE OR PERMIT.
Business Name and Address (License/Permit Issued Under)

The Business is (Check one)
Individually Owned

A Partnership

License or Permit Number

A Corporation

Expiration Date of Latest License
or Permit

Other (Specify)

19a. I believe i should be granted relief because:

19b. Important: Applicants filing for restoration privileges (Relief From Disabilities) under Chapter 44, Title 18 U.S.C. 925(c) must complete this item.
No application for restoration under 18 U.S.C. Chapter 44 will be considered unless the applicant acknowledges and agrees that a notice of approval will appear in the Federal Register,
an official U.S. Government publication available to the general public, if and when the application is approved. The notice of approval will give all essential details including the applicant’s
name, address, the court and date of conviction.
IN THE EVENT THIS APPLICATION IS APPROVED:
I understand that a notice of approval will appear in the Federal Register immediately following the issuance of the approval, and
I hereby agree to publication of the notice of approval giving my name, address and the date of my conviction.
Under penalties imposed by 18 U.S.C. 924, I declare under penalties of perjury, that the answers in this application are true, correct, and
complete.
20. Signature of Applicant

21. Date

Note: A Completed Fd 258 (Fingerprint Identification Card) Must Accompany This Application.
Mail Application Form To:

Bureau of Alcohol, Tobacco, Firearms and Explosives
Tech World Post Office, P.O. Box 50220
Washington, DC 20091
Important Notices

1. Under 18 U.S.C. 922(g)(8) firearms may not be sold to or received by persons subject to a court order that: (A) was issued after a hearing of which
the person received actual notice and had an opportunity to participate; (B) restrains such person from harassing, stalking or threatening an intimate
partner or child of such intimate partner or person, or engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury
to the partner or child; and (C)(i) includes a finding that such person represents a credible threat to the physical safety of such intimate partner or child,
or (ii) by its terms explicitly prohibits the use, attempted use, or threatened use of physical force against such intimate partner or child that would
reasonably be expected to cause bodily injury. An “intimate partner” is a person defined in section 921(a)(32).
2. Under 18 U.S.C. 922(g)(9) firearms may not be sold to or received by persons who have been convicted of a misdemeanor crime of domestic violence
as defined in section 921(a)(33).
ATF Form 3210.1
Revised July 2003

Additional Information
Applications for restoration of firearms privileges must include the following information where applicable. Please note that any record or document of a
court or other government entity or official required to be furnished as indicated below shall be certified by the court or other government entity or official
as a true copy.
(1) In the case of an applicant having been convicted of a crime punishable by imprisonment for a term exceeding one year, a copy of the indictment
or information on which the applicant was convicted, the judgement of conviction or record of any plea of nolo contendere, or plea of guilty or
finding of guilt by the court must be provided.
(2) In the case of an applicant under indictment or information, a copy of the indictment or information must be provided.
(3) In the case of an applicant who has been adjudicated a mental defective or committed to a mental institution, the following must be provided with
your application: a copy of the order of a court, board commission or other lawful authority that made the adjudication or ordered the commitment;
any petition that sought to have the applicant so adjudicated or committed; any medical records reflecting the reasons for commitment and
diagnoses of the applicant; and, any court order or finding of a court, board, commission, or other lawful authority showing the applicant’s
discharge from commitment, restoration of mental competency, and the restoration of rights.
(4) In the case of an applicant who has been discharged from the Armed Forces under dishonorable conditions, a copy of the applicant’s summary
of service record (Department of Defense Form 214), charge sheet (Department of Defense Form 458), and final court martial order must be
provided.
(5) In the case of an applicant who is subject to a protection order that restrains that individual from threatening an intimate partner, a copy of the
court order, court record, and other records reflecting relevant information including the terms and duration of the order, the identities of the
parties, and the parties’ opportunity for a hearing and/or hearing date.
(6) In the case of an applicant who has been convicted of a misdemeanor crime of domestic violence, a copy of the indictment or information on
which the applicant was convicted, the judgment of conviction or record of any plea of nolo contendere or plea of guilty or finding of guilt by the
court. Documents incorporated by reference in the indictment, information, judgment of conviction, or other official record(s) also should be
included (e.g., police reports). Records should reflect information including date of conviction, specific statutory violation, location of court, and
identity of victim.
(7) In the case of an applicant who, having been a citizen of the United States, has renounced his or her citizenship, a copy of the formal renunciation
of nationality before a diplomatic or consular officer of the United States in a foreign state, or before an officer designated by the Attorney General
when the United States was in a state of war, must be provided. See 8 U.S.C. 1481(a)(5) and (6).
(8) In the case of an applicant who is a lawful alien, several certifications may be required. Please contact ATF for sample certifications.

Privacy Act Information
The following information is provided pursuant to Sections 3 and 7(b) of the Privacy Act of 1974:
1. Authority. Solicitation of this information is made pursuant to 18 U.S.C. Chapter 44. Disclosure of this information by the applicant is mandatory if the
applicant wishes to seek relief from disabilities, i.e., restoration of firearms privileges.
2. Purposes. To determine whether the applicant is eligible to apply for relief from disabilities under 18 U.S.C. § 925(c); and to determine whether the
restoration of privileges should be granted.
3. Routine Uses. The information will be used by ATF to make the determinations set forth in paragraph 2. In addition, the information may be
disclosed to other Federal, State, foreign and local law enforcement and regulatory agency personnel to verify information on the application and to
aid in the performance of their duties with respect to the regulation of firearms and ammunition. The information may further be disclosed to the
Justice Department if it appears that the furnishing of false information may constitute violation of Federal Law.
4. Effects of Not Supplying the Information Requested. Failure to supply complete information will delay processing and may cause denial of the
application.
5. Disclosure of Social Security Number. Disclosure of the individual’s social security number is voluntary. Solicitation of this information
is made pursuant to 18 U.S.C. § 925(c), and E.O. 9397, Nov. 22, 1943, and may be used to verify the identity of the applicant.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The information is required in order to determine whether or not firearms
privileges may be restored. It is used to conduct an investigation to establish if it is likely that the applicant will act in a manner dangerous to public
safety or contrary to public interest. The information is required in order to restore privileges under 18 U.S.C. 925(c).
The estimated average burden associated with this collection of information is 30 minutes per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports
Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.

ATF Form 3210.1
Revised July 2003

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Authority for Release of Information

Authority for Release of Information
THIS SHEET MUST ACCOMPANY ALL COPIES OF ATF FORM 3210.1, APPLICATION FOR RESTORATION OF FIREARMS PRIVILEGES
1. Authority. The authority to solicit information is stated in ATF Form 3210.1, Application for Restoration of Firearms Privileges. This form is in compliance with the Privacy Act of 1974.
2. Purpose and Use. The information you supply by signing this release of information form will be used principally to aid in the completion of a background investigation conducted by the Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), pursuant to 18 U.S.C. §
925(c), in conjunction with your Application for Restoration of Firearms Privileges.
3. Effects of Nondisclosure. Your signature on this Authority for Release of Information form is voluntary; however, your failure to complete this form
may mean that the required information cannot be obtained to complete your investigation, and may result in the termination of your application.
Name of Applicant (Include Last, First, and Middle Name and all aliases used)

Date of Birth

Present Address (Number, Street, City, State, Zip Code)

Telephone Number (Include Area
Code)

This release, when presented by a duly authorized representative of the Department of Justice, will constitute my consent and authority to
examine and obtain copies and abstracts of records and to receive statements and information regarding my background. Specifically, I
hereby authorize the release of the following data or records to the Department of Justice (ATF):
Employment Information, Military Information/Records, Police and Criminal Records, Medical History
Medical Information Records
If You Answered “Yes” to Items 16(b) or (F) on ATF Form 3210.1, Complete the Following Section.
Name of Attending Physicians, Alcohol or Drug Abuse
Rehabilitation Centers, or Mental Health Institutions

Signature of Applicant

Address
(Including City, State and Zip Code)

Area Code and
Telephone Number

Special Agent (Signature)

Date

Date

ATF Form3210.1
Revised July 2003