STATE OF NEW JERSEY
CERTIFICATE OF ELIGIBILITY

(This form must be completed for each transfer of a Shotgun, Rifle, including black powder or BB Rifle)

Part 1: This section must be completed by the transferor (seller or giver) of the firearm

Make of Firearm__________________ Action (Pump, Lever, Semi-Automatic, Bolt etc.) __________

Model of Firearm: _____________Caliber or Gauge: ________ Serial #:_____________________

Name of Transferor (or Dealer Employee): Last _______________ First___________Mid. Init _____

Dealer Name (if applicable): ____________________Dealer's State License Number ___________

Address of Transferor: Street _________________Town/City_________State____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 firearm.

Name of Receiver: Last_______________________First____________________Mid. Init_______

Addres: Street _____________________Town/City_____________State______Zip Code________

Date of Birth: ________________ Firearms I.D. Card Number: _____________________________

1) Have you ever been convicted of a crime that has not been expunged or sealed? ___Yes ____No
2) Are you subject to any court order prohibiting you from possessing firearms? _____Yes _____No
3) Are you subject to any court order issued pursuant to Domestic Violence? _____Yes _____No
4) Have you ever been convicted of any domestic violence in any jurisdiction, which involved the elements of (1) striking, kicking, shoving or (2) purposely, or attempting to or knowlingly or recklessly causing bodily injury, or (3) negligently causing bodily injury to another with a deadly weapon? _____Yes _____No
5) Are you an alcoholic? _____Yes _____No
*Note: A recovered alcoholic may answer NO to this question.
6) Are you dependent upon the use of any narcotic or other controlled dangerous substance? _____Yes _____No
7) Do you suffer from any physical defect or sickness which makes it unsafe for you to handle firearms? _____Yes _____No
8) Have you ever been confined for a mental disorder? _____Yes _____No
b Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of violence, either to overthrow the government of the United States or of this State, or to deny others of their rights under the Constitution of either the United States or the State of New Jersey? _____Yes _____No
10) Are you a fugitive from justice? _____Yes _____No
11) What is your State of residence__________________________________________________

If other than NJ, this transfer must go through a licensed firearms dealer.

__________________________________________________________
Signature of Receiver

Original is to be retained by the transferor (giver/seller) pursuant to N. J. S. A. 2C:58-3b. Copy is to be retained by the receiver.

Should you have any questions in completing this form, contact the Firearms Investigation Unit, New Jersey State Police, P. O. Box 7068, West Trenton, NJ 08628-0068, (609) 882-2000 Ext. 2664.

Questions 1 - 10 must answered "No" for the transfer of the firearm to proceed. A person who answers "yes" to any question is not eligible to receive a firearm.

S.P. 634 (Rev. 12/00)


Print and complete two copies - Seller retains original and Receiver retains the copy

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