WESTERN AUSTRALIA POLICE
Form 22
Storage Statement
(Statutory Declaration)
Western Australia Firearms Act 1973 (R.11C)
STATE CRIME
Licensing Enforcement Division
Licensing Services
303 Sevenoaks St, CANNINGTON WA 6107
MAIL TO: Locked Bag 9, EAST PERTH WA 6892
TELEPHONE: 1300 171 011
EMAIL: [email protected]
Application Number
This Storage Statement is provided in support of my firearm application.
Licence Number
This Storage Statement is provided as I have changed my address and reinstalled my storage cabinet.
Person Making Statutory Declaration
Family Name
Date of Birth
All Given Names
Unit / Lot / Level
Street Number
Street Name
Street Type
State
Home Phone
Suburb
Post Code
Work Phone
Mobile Phone
Email
Declaration
I, the person described above, sincerely declare as follows;
To ensure that any firearm or ammunition in my possession is stored in accordance with the Firearms Regulations 1974
r. 11A, I have;
A lockable cabinet or container described below that at least meets the specifications described in Schedule 4 of
those regulations in both construction and anchoring.
A separate lockable metal container described below that is securely affixed to the above cabinet or container, in
which to store ammunition
Description of Storage Arrangement
Commercialy Produced
or
Custom Made
Handgun Storage Capacity
Long Arms Storage Capacity
Make and Model
(if known)
Description of construction
and how the cabinet has
been anchored. Including
size of washers/plate etc.
Details of any additional
security measures in place
(Eg: CCTV, alarm system)
Form 22 Storage Statement 1.0 20/07/2015
LSF12
WESTERN AUSTRALIA POLICE
STATE CRIME
Licensing Enforcement Division
Licensing Services
Storage Statement
(Statutory Declaration)
Western Australia Firearms Act 1973 (R.11C) Form 22
303 Sevenoaks St, CANNINGTON WA 6107
MAIL TO: Locked Bag 9, EAST PERTH WA 6892
TELEPHONE: 1300 171 011
EMAIL: [email protected]
Alternate Storage Arrangement - (Only to be completed if storage is alternate to Schedule 4)
Provide details of your alternate storage below:
The storage location of my firearms is the same as my residential address. (If no, provide further details below)
Unit / Lot / Level
Street Number
Yes
No
Street Name
Street Type
Suburb
Post Code
Statutory Declaration (Applicant or Licensee to complete)
Proof of purchase/fitting of an approved lockable cabinet or other storage facility attached.
Photographs of approved lockable cabinet or other storage facility attached.
This declaration is true and I know that it is an offence to make a declaration knowing that it is false in a material particular.
This declaration is made under the Oaths, Affidavits and Statutory Declarations Act 2005
at
Applicant/Licensee Signature
on
D
D
M
/
M
Y
/
Y
Y
Y
by:Authorised Witness Signature
in the presence of this authorised witness:-
Witness Name
Witness Qualification
Form 22 Storage Statement 1.0 20/07/2015
LSF12
WESTERN AUSTRALIA POLICE
STATE CRIME
Licensing Enforcement Division
Licensing Services
303 Sevenoaks St, CANNINGTON WA 6107
MAIL TO: Locked Bag 9, EAST PERTH WA 6892
TELEPHONE: 1300 171 011
EMAIL: [email protected]
Authorised Witnesses under Schedule 2 of the Oaths, Affidavits and Statutory Declarations Act 2005
Academic (post-secondary institution)
Accountant
Architect
Australian Consular Officer
Australian Diplomatic Officer
Bailiff
Bank manager
Chartered secretary, governance adviser or risk manager
Chemist
Chiropractor
Company auditor or liquidator
Court officer
Defence force officer
Dentist
Doctor
Electorate officer of a member of State Parliament
Engineer
Industrial organisation secretary
Insurance broker
Justice of the Peace
Landgate officer
Form 22 Storage Statement 1.0 20/07/2015
Lawyer
Local government CEO or deputy CEO
Local government councillor
Loss adjuster
Marriage celebrant
Member of Parliament
Minister of religion
Nurse
Optometrist
Patent attorney
Physiotherapist
Podiatrist
Police officer
Post office manager
Psychologist
Public notary
Public servant (Commonwealth)
Public servant (State)
Real estate agent
Settlement agent
LSF12