I. I, ______________________#______, an Officer with _________________,
      (Full name of officer) (Dept ID#)              (Dept. Name)
am authorized to purchase the following weapon to be used in the 

performance of my official duties.  I certify under penalty of perjury 

that the firearm is not being purchased for personal use or for the 

purposes of transfer or resale.

Exact Firearm Description 

 _____________________   _________   ________  _____________________   
 (Firearm Make)          (Model #)   (Caliber) (officer contact ph#)

II. I, ____________________________, herby certify that the above named 
        (Full name of supervisor)
law enforcement officer is currently employed with the _______________, 
                                                       (Dept. Name)
and the firearm being purchased will be used by the officer in the 

performance of official duties. 

    I further certify that a records check has been conducted on the 

law enforcement officer who is purchasing the firearm and reveals no 

convictions for misdemeanor crimes of domestic violence.

___________________________    ___________________________ 
(Signature of Supervisor)      (Name of officer requesting purchase) 

___________________________    ___________________________
(Name of Supervisor)           (Date)

___________________________    ___________________________
(Department Address)           (Supervisor's Office Phone #)