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Part 3(b) – Reason for Exemption Application

Absent from the State for a substantial period of time (for a period greater than 1 month)

Effective from

NOTE: A travel Itinerary, tickets, passport or similar document, letter from employer signed and dated or Statutory Declaration must be

provided confirming your absence from the state for the period of time indicated on this application and must include your contact details for

the absent period and any other evidence e.g. documents that will support your application for exemption.

Temporarily physically incapacitated (for a period greater than 1 month)

Effective from

NOTE: A medical certificate is required stating the nature of the condition, expected duration, impact on ability to operate a firearm and the

contact details of the signing medical practitioner and any other evidence e.g. documents that will support your application for exemption.

Firearm Storage - In order for a determination to be made as to whether your firearm(s) may be required to be stored with another licence

holder or Licensed Firearms Dealer during the exemption period for the above reasons, please attach a separate page outlining the following:

The storage address your firearm(s) will be stored at during the exemption period.

If the firearm(s) are to be stored at another licence holders storage facility or with a Licensed Firearms Dealer please specify their

full name, address and licence details.

If the storage address will be occupied during your absence, please provide details i.e. occupier(s) full name, arrangements to

prevent access to firearm(s).

Have you arranged for any additional security arrangements e.g. alarms? Please specify.

Other reason(s) that has impacted on your ability to meet the annual participation requirement (for a period greater

than 1 month)

Effective from

NOTE: Please provide separately a detailed description explaining what will preclude you from meeting your participation requirements

and include any evidence e.g. documents that will support your application for exemption. If you participated interstate /overseas you must

provide a signed, dated letter (on registered club or organisational letterhead) or scorecard which provides the type, date and number of

the matches/shoots undertaken the handgun class and contact details of the club or range where the match/shoot took place. All provided

documentation must be endorsed by your nominated principal club.

Part 4 – Prescribed Handgun Class Details

Classes of handgun for which modification (variation)/exemption is required

Place a cross in the appropriate box(es) below to indicate the prescribed class(es) that you require an modification

(variation)/exemption for:

Class 1 – Air handgun

Class 2 – Rimfire handgun

Class 3 – Centrefire handgun with a calibre of .38 inch or less OR a black powder handgun

Class 4 – Centrefire handgun with a calibre of more than .38 inch but no more than .45 inch

Part 5 - Acknowledgment

I acknowledge that the particulars in this application and any attachments are true and correct and I make this acknowledgment knowing this

it is an offence against section 140A(1) of the Firearms Act 1996 to wilfully supply details that are false or misleading (maximum penalty 240

penalty units or 4 years imprisonment).

Signature

Date

Privacy Statement: The information collected in this application is being collected by Victoria Police. It will be used in accordance with the

provisions of the Firearms Act 1996, Private Security Act 2004, Control of Weapons Act 1990 and the Information Privacy Act 2000. Your

information may be disclosed to employers, approved bodies and other statutory authorities by Victoria Police for the purpose of law

enforcement and the administration of justice. Applicants may gain access to their information through application to the Victoria Police

Freedom of Information Unit.

Health Privacy Statement: The health information collected in this application is being collected by Victoria Police. The health information

in accordance with the

collected will be used

provisions of the Firearms Act 1996, Private Security Act 2004, Control of Weapons Act

1990 and the Health Records Act 2001, and is required to be collected under the Firearms Act 1996. Your health information may be

disclosed to approved bodies and/or statutory authorities for purposes related to the administration of the above Acts, for the purpose of law

enforcement or, if necessary, for the establishment, exercise or defence of a legal or equitable claim. Applicants are able to gain access to

their health information through application to the Victoria Police Freedom of Information Unit.

12/08

Vp Form 1311 - Application For Modification (Variation) To Or Exemption From Handgun Target Shooting Participation Page 2

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