Employee Possessor Questionnaire (2022)

OUR INFORMATION

What's an "Employee Possessor"? An "Employee Possessor" is someone who is required to handle regulated explosives (fireworks) as a requirement of their job. Not all jobs require someone to handle explosives.

4. Aliases (Include given, married, maiden names)

If you have changed your name due to marriage or other life event, include your original birth name.

6. Social Security Number

This is optional, but will help prevent misidentification.

8. Place of Birth (City and State)*

If you were not born in the United States, include the city/province and country of your birth.

11. Telephone Number (including area code)*

13. Driver's License or State ID Number (include State of issuance)*

14. Previous Address(es)

Please provide residential history and dates for the past five years. If you have not moved addresses in the last five years, you can skip this question.

PHYSICAL DESCRIPTION

17. Weight*

Enter in lbs.

BACKGROUND

If answering "Yes" to any of the following questions, please provide details in the space provided.

NOTE: If you currently work for multiple companies that have a Federal Explosives License in which you are listed as an Employee Possessor, contact us. You may need to manually fill out this form.

Please include the Federal Explosives Licensee or Permittee number below...

Don't know their FEL number? Just include the name of the company or business. We will track down their FEL number.

Please include the Federal Explosives Licensee or Permittee number below...

Don't know it? Just include the name of the company or business and we'll find the FEL number.

Please provide full details below...

Briefly explain the reasoning for your dishonorable discharge...

Name of Other Country (or Countries)

List all countries you are a legal citizen.

38. If you are an alien, record your U.S.-Issued Alien or Admission Number

39. Under the penalties imposed by 18 U.S.C. §§ 842 and 1001, I declare that I have examined any related documents submitted in regard to this questionnaire (ATF Form 5400.28), and to the best of my knowledge and belief, they are true, correct and complete. This signature, when presented by a duly authorized representative of the U.S. Department of Justice, will constitute consent and authority for the appropriate U.S. Department of Justice representative 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 ATF: military information/records, medical information/ records, police and/or criminal records.*

Signature Required

Please write your name as it appears above in your signature*

RENEWAL PERMISSION

This is optional but will save you time in the future.

NOTE: A copy of this form may be used for your renewal submission. I certify, under penalties of perjury, that my answers on this form are still true, accurate and complete.

Signature (For second submission)

UPLOAD ITEMS

This is where you can upload any required supporting documents.

Upload any supporting documents needed to complete your submission

Max. file size: 64 MB.

Ex: Letter for Relief of Disability

Please provide additional information if you answered "Yes" to any of questions #29-37.

Include the question number followed by additional information as to why you answered "Yes" to any one of questions #29-37.

EX: 29 - I answered yes because...

Pyro Shows

EMPLOYEE POSSESSOR QUESTIONNAIRE (2022 Edition)

OUR INFORMATION

YOUR INFORMATION

PHYSICAL DESCRIPTION

BACKGROUND

SIGNATURE

RENEWAL PERMISSION

UPLOAD ITEMS

Tennessee

Alabama

Texas

South Carolina