FORM 4A
QUEENSLAND
Weapons Act 1990
Section 24
Ver. 4 — 28/10/2016
Δ1
1. NOMINATE CHANGE(S)
2. LICENCE NUMBER(S) AFFECTED BY THIS CHANGE
Place a cross in
applicable box(es).
3. LICENSEE/REPRESENTATIVE DETAILS
Family name
Please use
BLOCK LETTERS.
Given name(s)
Date of birth
MonthDay Year
Change of residential address Change of postal address
4. NEW RESIDENTIAL/POSTAL ADDRESS
5. PREVIOUS RESIDENTIAL/POSTAL ADDRESS
Form 4A Change of Address (Residential/Postal Only)/Change of Name/Change of Weapon(s) Secure Storage Facility Page 1 of 2
Contact details
Work
FaxMobile
Home
Email
Property name/
Lot on plan
Street number
and name
Street number
and name
Suburb/Locality
Suburb/Locality
State
State
Postcode
Postcode
How long have you
lived at this address?
How long have you
lived at this address?
Weeks
Months
Months
Years
Postal address
(e.g., PO Box)
Postal address
(e.g., PO Box)
Suburb/Locality
Suburb/Locality
State
State
Postcode
Postcode
Address (Residential/Postal only) Complete sections 1, 2, 3, 4, 5, 7 and 9 only.
Name(s) Complete sections 1, 2, 3, 6 and 9 only.
Weapon(s) Secure Storage Facility Complete sections 1, 2, 3, 8 and 9 only.
Place a cross in
applicable box(es).
Property name/Lot on
plan (RP no.) can be
found on rates notice.
CHANGE OF ADDRESS• (Residential/Postal Only)
CHANGE OF NAME(S)•
C• HANGE OF WEAPON(S) SECURE STORAGE FACILITY
*--0000*
0000
*--0015*
0015
6. CHANGE OF NAME(S)
Does your change of address affect the genuine reason for which your licence is currently issued? (e.g., Has the
property where you will be using the weapon(s) changed?)
8. WEAPON(S) SECURE STORAGE FACILITY
Form 4A Change of Address (Residential/Postal Only)/Change of Name/Change of Weapon(s) Secure Storage Facility Page 2 of 2
Previous name(s)
Current name(s)
You must provide proof of change of name e.g., marriage certicate, deed poll certicate, dissolution of
marriage certicate or driver licence.
Yes
(Refer to specic requirements below) No (Continue to question 9)
Documentation to support this change of name(s) is attached.
Sufcient information to support the change of weapon(s) storage facility
has been provided.
I have sighted sufcient documentation to support this change of address.
9. LICENSEE CERTIFICATION
OfcerinCharge
Name of receiving station
I certify that the information I have given is true and correct in every detail and have attached all
required documentation.
and it complies with the Weapons Act 1990 and the Weapons Regulation 2016.
7. GENUINE REASON(S)
Primary producer/Rural employee—Provide a completed Form 1 Annexure—Occupational/Rural Purposes.
Sports or Target Shooting (Category A & B)—Provide proof of current nancial membership of an approved
club. The proof is to clearly show the club name, your name and the expiry date of your membership.
Recreational shooting
—Provide a completed Form 1 Application for a Licence—Annexure—Recreational
Shooting completed by a landowner for a property of 40 acres or larger.
I hereby declare that I have access to a secure storage facility located at
10. POLICE STATION USE ONLY
Postcode
Street number
and name
Property name/
Lot on plan
State
Suburb/Locality
Provide a description of the new secure storage facility and the reasons why the weapon(s) are not stored at your
residential address. If insufcient space, provide further information on a blank page and attach to this form.
Signature of licensee/representative
MonthDay Year
Date
MonthDay Year
Date
Privacy Collection Statement
The collection of this information is authorised by the Weapons Act 1990. The information will be used for the
administration and enforcement of the Weapons Act 1990. The information you provide will not be used or disclosed
without your consent unless such use or disclosure is authorised or required by law, including the Weapons Act 1990
(Qld), Police Service Administration Act 1990 (Qld) and the Information Privacy Act 2009 (Qld). You have a right to
access personal information that the QPS holds about you, subject to any exceptions in relevant legislation. If you wish to
seek access to your personal information or inquire about the handling of your personal information, please contact PSBA
Right to Information and Privacy by email at rti@police.qld.gov.au or by telephone 07 3364 4666.
Name
Name
Rank and Reg. No./
Level and payroll no.
Signature
Rank and Reg. No.
Signature
Receiving member
CERTIFY AND
SIGN HERE
