I CERTIFY that I am not prohibited by and Federal, State or Local laws to                                               purchase, own or possess the ammunition ordered.    I further certify that I am at least 21 years of age.
 

---

AN ENLARGED COPY OF YOUR CURRENT DRIVER'S LICENSE IS REQUIRED
Must be sent via U.S. Mail - Faxed Copies will not be accepted.

---

   ____________________________________                       _________________________
              SIGNATURE                                                                 DATE
 

    ____________________________________                    __________________________
           PRINTED NAME                                                              PHONE
 

    ____________________________________                    __________________________
          ADDRESS OF RESIDENCE                                     COUNTY OF RESIDENCE

 

              NOTE:  LAW PROHIBITS the purchase of ammunition by minors, drug
                            addicts, convicted felons, illegal aliens, those convicted of a
                            misdemeanor crime of domestic violence or the mentally ill.
                            If you are un-sure of the specific legal requirements in your area,
                            please check with your local law enforcement authorities and/or your
                            Bureau of Alcohol, Tobacco & Firearms office.