OMB No. 1512.0028 (02/20/2004) AVF GONTRO! NUMBER a DEPARTMENT OF THE TREASURY BUREAU OF ALCOHOL, TOBACCO AND FIREARMS APPLICATION TO MAKE AND REGISTER A FIREARM (Submitin dupicate. Soe Instructions attached) ag ‘TO: National Firearms Act Branch, Bureau of Alcohol, Tobacco and Firearms, Washington, DG 20226 ‘Tho undersigned hereby makes application, as required by Sections 5821 and 5822 ofthe aional FKo- arms Act, Tilo 26 U.S.C.,Cnaptor 53, to make and register the rear described below. 2 APPLICATION IS MADE BY, a, TRADE NAME (any) coun [7] conporaronoronier 7] coveaeun fusmessennry fay TON (hack ona ‘twith your application @ order for $200 made ‘artment of tho Treasury the application, this - ale, and cancel the i Firearms Act stamp 3b, APPLICANT'S NAME AND MAILING ADDRESS. (Type or print below and between the dels) . . H Y} ndopendont establish ‘ent, or agency there []>. 10% exeMPT because firearm is being made by or on behalf of any Stata or pos- SOF EO BOK IS SHOWIN AGE SVREET ASSESS HUST SE GEER] Stesion ot ne United States. or any pot Je: IF RO. BOX IS SHOWN ABOVE, STREET ADDRESS MUST BE GIVEN HERE doa subdldoon hersol ay oes _ police organization of such a govesnment oe fle. TELEPHONE AREA CODE AND NUMBER tenity engaged in criminal investigations. IMPORTANT: COMPLETE THE REVERSE SIDE. INDIVIDUALS (INCLUDING FEDERALLY LICENSED COLLECTORS) MUST ALSO SUBMIT, IN DUPLICATE, Fl FORM FD-258, FINGERPRINT CARD. PSS ON EN TS ET — a NAME AND LOCATION OF ORIGINAL MANUFAC: |b. TYPE OF FIREARM TO BE |c, CALIBER, | (AR-IS DAS. Me cieoce ree mai, Aes, (STF Ora ove ad (Specity) vdieo | SERBS pallial 5 ADDITIONAL DESCRIPTION (Include ailnumbers and otherldentiving || STATE WHY YOU INTEND TO WAKE FIREARM (Use addtional shoot? setbed on i, pase note the flowing information ESTATE PROCEDURES: For procedures regarding the uansir of frams an esate « alae he NFA Branch, Gueau of ATF. Wastington, OC 2026. ing om the death ofthe regsran Monten em 3, the exer should ‘CHANGE OF ADDRESS: ‘The ryan shal nity te NFA Brveh, Buea of coal, Tabacco and Farms, Washnglan, DC 20226, ning, ct any change to the ates In tem 32, INTERSTATE MOVEMENT: 1 th, trarm wertied in tem 4 @ mochinegun, shor baled ie, short-barreed shotgun. or dest 1 deve, the registrant may be required by 18 US.C. § 92214) fo aban permission ta ATF pre to any anspeiton in etre o oregn commerce ‘CHANGE OF DESCRIPTION: The reqsant sal noty the NER Branch, Bureau of Aeahol. Tobacco and Fears, Washington, OC 20226, in wring, of any chong to the desertion ofthe feeaems in term 4 RESTRICTIONS ON POSSESSION: Any restieson (ee appzoval lok on faceoff) on he possession of he fear Mntid in Hom 4 ca he ter wansfer ofthe tear, PERSONS PROHIBITED FROM POSSESSING FIREARMS: 1th ryistare Becomes prohibited Yy 18 USC. § 92 rom possess a Hed, tas regan 924 the NFR Branch, Bureau of Aeaba Tobacco and foams, Whshaen, DC 20228, in ing tmedtlyypon becoming pron Yor un oa the dpe PROOF OF REGISTRATION: This op of ot an an shall te mae aval to any AN ais wpa