ATF-Reg-Form – Ezebreak LLC Micro-Blaster

Ezebreak Registration Form

This Online Form is to be filled out by each purchaser prior to the sale of Ezebreak Micro-Blaster Cartridges to satisfy requirements of the ATF Variance (exemption) to Part 555 of current ATF regulations. Online forms are stored exclusively by Ezebreak in a secure database for a period of five years. Ezebreak Dealers have confidential credentials to verify customer registration. Information will only be released to ATF if there is a reasonable suspicion of illegal activity involving our products. Information is not disclosed to any other parties. Registered customers will only need to fill out another form if their information changes or has expired after 5 years, whichever comes first.

By Checking, Entering, and Signing/Submitting Below I Certify:

THAT I AM OVER THE AGE OF 18 AND OF OF SOUND MIND. . .

THAT I WILL STORE MICRO-BLASTER CARTRIDGES IN A SAFE AND SECURE LOCATION AWAY FROM HEAT, FLAMMABLES, AND MINORS (e.g. under lock and key)

THAT I WILL USE MICRO-BLASTER CARTRIDGES AND ASSOCIATED EQUIPMENT ONLY AS THESE PRODUCTS ARE INTENDED AS DESCRIBED IN EZEBREAK MANUALS AND VIDEOS.

THAT I FULLY UNDERSTAND IT IS UNSAFE AND ILLEGAL TO SUBSTITUTE OR USE MICRO-BLASTER CARTRIDGES IN ANY OTHER WAY THAN THE MANUFACTURER HAS INTENDED.

THAT I WILL NOT ALLOW PERSONS UNDER THE AGE OF 18 TO USE OR POSSES MICRO-BLASTER CARTRIDGES (LOADS) AND THAT I WILL COMPLY WITH FEDERAL, STATE, AND LOCAL LAWS.

USER NAME, LAST:

FIRST & MIDDLE:

COMPANY:

PHYSICAL ADDRESS:

CITY:

STATE:

ZIP-5:

PHONE:

EMAIL:

Re-enter EMAIL:

INTENDED PURPOSE:

SIGNATURE: _______________________________________________(for printed forms)

SIGNATURE

DATE:

----------------------------------- DEALER SECTION -----------------------

DEALER NAME:

SIGNATURE: _______________________________________________(for printed forms)

SALESPERSON:

SIGNATURE: _______________________________________________(for printed forms)

You will have an opportunity to review your information
before final submission. Click HERE if you wish to clear the form.

EZEBREAK, PO BOX 29, FRANKFORD, WV 24938 WWW.EZEBREAK.COM 304-497-9970

8/04/2016