ATF Form 5400.29 Application for Restoration of Explosives Privileges

ATF Form 5400.29 is a U.S. Department of Justice - Bureau of Alcohol, Tobacco, Firearms and Explosives form also known as the "Application For Restoration Of Explosives Privileges". The latest edition of the form was released in November 1, 2015 and is available for digital filing.

Download a PDF version of the ATF Form 5400.29 down below or find it on U.S. Department of Justice - Bureau of Alcohol, Tobacco, Firearms and Explosives Forms website.

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U.S. Department of Justice
OMB No. 1140-0076
Application for Restoration of
Bureau of Alcohol, Tobacco, Firearms and Explosives
Explosives Privileges
1. Name (Last, First, Middle)
2. Birthplace (City & State or Foreign
3. Date of Birth
4. Aliases
5. Social Security Number (Voluntary)
Country)
6a. Residence Address (No., Street, City, County, State, ZIP Code; cannot be a post office box)
7a. Telephone Number
7b. Cell Phone Number
6b. Mailing Address
7c. Email Address
8. Description
Ethnicity
Yes
No
Are you Hispanic or Latino?
Race (Check one or more boxes)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
White
Sex
Height
Weight
Hair
Eyes
9. Residences During Past Ten Years Beginning With Current Residence (In columns (b) and (c) enter the months and years of residence.)
Address (Number, Street, City, State Zip Code, and Country)
From
To
(a)
(b)
(c)
10. Employment Record (List present and prior employers and show month and year of employment.)
Name and Address of Employer
Position
From
To
(a)
(b)
(c)
(d)
11. Convictions (If pardoned for a conviction, write "yes" in column (e) and attach a certified copy of the pardon.)
Specific Crime
Name and Location of Court
Sentence Received
Conviction Date
Pardoned
(a)
(b)
(c)
(d)
(e)
12. Other Arrests
Charge
Date and Place of Arrest
Disposition
(a)
(b)
(c)
13. Probation Officer's Name, Address and Telephone Number
14. Parole Officer's Name, Address and Telephone Number
ATF E-Form 5400.29
Revised November 2015
U.S. Department of Justice
OMB No. 1140-0076
Application for Restoration of
Bureau of Alcohol, Tobacco, Firearms and Explosives
Explosives Privileges
1. Name (Last, First, Middle)
2. Birthplace (City & State or Foreign
3. Date of Birth
4. Aliases
5. Social Security Number (Voluntary)
Country)
6a. Residence Address (No., Street, City, County, State, ZIP Code; cannot be a post office box)
7a. Telephone Number
7b. Cell Phone Number
6b. Mailing Address
7c. Email Address
8. Description
Ethnicity
Yes
No
Are you Hispanic or Latino?
Race (Check one or more boxes)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
White
Sex
Height
Weight
Hair
Eyes
9. Residences During Past Ten Years Beginning With Current Residence (In columns (b) and (c) enter the months and years of residence.)
Address (Number, Street, City, State Zip Code, and Country)
From
To
(a)
(b)
(c)
10. Employment Record (List present and prior employers and show month and year of employment.)
Name and Address of Employer
Position
From
To
(a)
(b)
(c)
(d)
11. Convictions (If pardoned for a conviction, write "yes" in column (e) and attach a certified copy of the pardon.)
Specific Crime
Name and Location of Court
Sentence Received
Conviction Date
Pardoned
(a)
(b)
(c)
(d)
(e)
12. Other Arrests
Charge
Date and Place of Arrest
Disposition
(a)
(b)
(c)
13. Probation Officer's Name, Address and Telephone Number
14. Parole Officer's Name, Address and Telephone Number
ATF E-Form 5400.29
Revised November 2015
15. 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 the applicant for at least 3 years, recommending the granting of relief.)
Name and Address
Occupation
Telephone Number
(a)
(b)
(c)
16. Applicant Data (All questions must be answered by checking "Yes" or "No" box.)
Questions
Questions
Yes
No
Yes
No
g. Have you ever been discharged from the armed forces under
a. Are you a fugitive from justice?
dishonorable conditions? (If "yes," see Additional Information 4.)
b. Are you an unlawful user of or addicted to marijuana or any
h. Have you served on active duty in the armed forces? (If "yes," check
depressant, stimulant, or narcotic drug, or any other controlled
Branch and complete following)
substance?
c. Have you ever been convicted in any court of a felony or any
Air
Coast
Army
Navy
Marines
other crime for which the judge could have imprisoned you for
Force
Guard
more than one year, even if you received a shorter sentence,
Service Serial Number
Date Entered Active Duty
including probation? (If "yes," see Additional Information 1.)
Kind of Discharge
Date of Discharge
d. Are you now on probation or parole?
e. Are you under indictment or information in any court for a felony
i. Have you ever renounced your United States citizenship? (If "yes," see
or any other crime for which the judge could imprison you for
Additional Information 5.)
more than one year? (An information is a formal accusation of a
crime by a prosecutor.) (If "yes," see Additional Information 2.)
j. Are you an alien in the United States? (If "yes," see Additional
Information 6.)
f. Have you ever been adjudicated mentally defective (which
INS-issued alien number or admission number:
includes having been adjudicated incompetent to manage your
own affairs) or have you been committed to a mental institution?
(If "yes," see Additional Information 3.)
k. Have you ever applied for a Federal explosives license or permit? (If
"yes," indicate date application filed.)
17. Complete This Item Only if You Were Ever Issued a Federal Explosives License or Permit.
Business Name and Address (License/permit issued under)
License or Permit Number
Expiration Date of Latest License or
Permit
The Business is (Check one)
Individually Owned
A Partnership
A Corporation
Other (Specify)
18. I Believe I Should Be Granted Relief Because:
Under penalties imposed by 18 U.S.C. 844, I declare under penalties of perjury, the answers in this application are true, correct, and complete.
19. Signature of Applicant
20. Date
Note: Two Completed FD 258 (Fingerprint Identification Cards) Must Accompany This Application.
E-Mail Application To: EROD@atf.gov
Mail Application Form To:
Bureau of Alcohol, Tobacco, Firearms and Explosives
NCETR - Relief of Disabilities Section
Corporal Road, Bldg. 3750, Redstone Arsenal, Huntsville, AL 35898
Phone Number 256-261-7640
Additional Information
Applications for restoration of explosives 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 certified 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, a certified 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 certified
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 diagnosis of the applicant and any certified 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.
ATF E-Form 5400.29
Revised November 2015
(4) In the case of an applicant who has been discharged from the Armed Forces under dishonorable conditions, a certified copy of the applicant's Certificate of Release or
Discharge from Active Duty (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, having been a citizen of the United States, has renounced his or her citizenship, a certified 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).
(6) In the case of an applicant who is an alien, the following must be provided with your application: documentation that the applicant is an alien who has been lawfully admitted
to the United States; certification from the applicant including the applicant's INS-issued alien number or admission number, country/countries of citizenship, and immigration
status, and certifying that the applicant is legally authorized to work in the United States, or other purposes for which possession of explosives is required; certification from
an appropriate law enforcement agency of the applicant's country of citizenship stating that the applicant does not have a criminal record; and, if applicable, certification from
a Federal explosives licensee or permittee or other employer stating that the applicant is employed by the employer and must possess explosive materials for purposes of
employment. These certifications must be submitted in English.
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 40. Disclosure of this information by the applicant is mandatory if the applicant wishes to
seek relief from disabilities, i.e., restoration of explosive privileges.
2. Purposes. To determine whether the applicant is eligible to apply for relief from disabilities under 18 U.S.C. 845(b); 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 explosives.
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.
845(b), 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 explosives 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. 845(b)
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 a currently valid OMB control number.
ATF E-Form 5400.29
Revised November 2015
U.S. Department of Justice
Authority for Release of Information
Bureau of Alcohol, Tobacco, Firearms and Explosives
This Sheet Must Accompany All Copies of ATF Form 5400.29, Application for Restoration of Explosives Privileges
1. Authority. The authority to solicit information is stated in ATF Form 5400.29, Application for Restoration of Explosives 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. 845(b), in conjunction with your Application for
Restoration of Explosives 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 denial 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, Country)
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 5400.29, complete the following section.
Name of Attending Physicians, Alcohol, or Drug Abuse
Address
Area Code and
Rehabilitation Centers, or Mental Health Institutions
Telephone Number
(Including City, State and Zip Code)
Signature of Applicant
Date
Special Agent (Signature)
Date
ATF E-Form 5400.29
Revised November 2015
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