Firearm Surrender Form | Exculta Health

SAFE Surrender Form

Full Legal Name

Users Address

Date of Birth

Phone Number

Identification #

Emergency Contact 1 Name

Emergency Contact 1 Address

Emergency Contact 1 Phone

Allowed to Retrieve Firearms?

Emergency Contact 2 Name

Emergency Contact2 Address

Emergency Contact 2 Phone

Allowed to Retrieve Firearms?

Firearm Make/ Manufacturer

Firearm Model

Firearm Serial #

Firearm Accessories

Firearm Condition Notes