Get MD MSP 77R-3 2013-2024

Maryland State Police Authorization for Release of Information to Purchase a Regulated Firearm Instructions This form must be submitted with MSP 77R Part 1 and Part 2. The Application number on Part 2 of the Application must be written in the spaces marked Application. Application Applicant Information Last Name First Middle Suffix Driver s License ID State Social Security Street Address Town/City State Zip Code Date of Birth Race Sex Male Female I First Name Middle Name Last Name authorize the Department of Health and Mental Hygiene or any other similar agency or department of another state to disclose to the Department of State Police information limited to whether I suffer from a mental disorder as defined in 10-101 f 2 of the Health General Article and have a history of violent behavior against anyone or whether I have been voluntarily admitted for more than 30 consecutive days or involuntarily committed to a facility or institution that provides treatment or services for individuals with mental disorders. I acknowledge that this information will be used solely as part of the investigation required by Title 5 Subtitle 1 of the Public Safety Article Annotated Code of Maryland to determine my eligibility to possess a regulated firearm* In the event that my Application to purchase a regulated firearm is disapproved I acknowledge that this authorization and any information obtained via this authorization may be used in any proceeding relating to the disapproval* I further acknowledge that I may at any time except to the extent that the Department of State Police has already taken action in reliance on it revoke this authorization by submitting a request for revocation in writing. If not previously revoked this authorization will terminate one year after the date I sign this Application or upon notification to me of the disapproval of this Application whichever occurs first. The Application number on Part 2 of the Application must be written in the spaces marked Application. Application Applicant Information Last Name First Middle Suffix Driver s License ID State Social Security Street Address Town/City State Zip Code Date of Birth Race Sex Male Female I First Name Middle Name Last Name authorize the Department of Health and Mental Hygiene or any other similar agency or department of another state to disclose to the Department of State Police information limited to whether I suffer from a mental disorder as defined in 10-101 f 2 of the Health General Article and have a history of violent behavior against anyone or whether I have been voluntarily admitted for more than 30 consecutive days or involuntarily committed to a facility or institution that provides treatment or services for individuals with mental disorders. Application Applicant Information Last Name First Middle Suffix Driver s License ID State Social Security Street Address Town/City State Zip Code Date of Birth Race Sex Male Female I First Name Middle Name Last Name authorize the Department of Health and Mental Hygiene or any other similar agency or department of another state to disclose to the Department of State Police information limited to whether I suffer from a mental disorder as defined in 10-101 f 2 of the Health General Article and have a history of violent behavior against anyone or whether I have been voluntarily admitted for more than 30 consecutive days or involuntarily committed to a facility or institution that provides treatment or services for individuals with mental disorders. I acknowledge that this information will be used solely as part of the investigation required by Title 5 Subtitle 1 of the Public Safety Article Annotated Code of Maryland to determine my eligibility to possess a regulated firearm* In the event that my Application to purchase a regulated firearm is disapproved I acknowledge that this authorization and any information obtained via this authorization may be used in any proceeding relating to the disapproval* I further acknowledge that I may at any time except to the extent that the Department of State Police has already taken action in reliance on it revoke this authorization by submitting a request for revocation in writing. .