APPLICATION FORM

Fields marked with an * are required

Application Type*
New ApplicationRenewal Application

PERSONAL DETAILS

Your full name*

Your date of birth (D.O.B.)*

Street*

Town*

County*

Postcode*

Telephone No.*

Email address*

Issuing Police Force*

GENERAL PRACTICE DETAILS

Name of GP*

Name of Practice/Surgery *

Street*

Town*

County*

Postcode*

Telephone No.*

Email address (optional)

MEDICAL CONDITIONS

Have you declared any medical conditions?
YesNo

If yes, please detail here... (optional)

SHOTGUN MEDICAL REPORT CONSENT FORM

We need your consent by ticking the box to complete this review. We will need a copy of your medical records and your formal permission to hold and review your records.

WHAT WE NEED

We will need a full copy of your medical records. You are entitled to a copy of your records, without charge, under the General Data Protection Regulations. Your GP practice is required to respond to your request and provide you with a copy of your records within 30 days. Your GP might offer you several alternatives. The copy we need must include all of your records including any letters and copies of any old records cards that may still exist but may be paper or electronic.

YOUR MEDICAL RECORDS

I will send my medical records via:*
PostEmail

Email address: [email protected]
Postal address: Technology House, Hadley Park East, Telford, TF1 6QJ

TERMS & CONDITIONS (please tick to confirm)

By checking this box, I confirm that I have read and understood the Shotgun Medical Report Consent Form detail above.*

By checking this box, I confirm that I have read and understood the terms and conditions outlined on this website*

By checking this box, I confirm that I give Shotgun Medicals permission to access, obtain and review my medical records for the sole purpose of acquiring a Shotgun or Firearms Medical Certificate*

How did you hear about us?*
BASCCPSA/Pull MagazineThe PolicePersonal recommendationWeb SearchOther

ACCEPTANCE & SIGNATURE

Print Name*

Please accept the ticking of this box as my E-signature*

Date*