TO                   :  HAWAII COUNTY POLICE DEPARTMENT

SUBJECT      :  SALE/TRANSFER OF RIFLE/SHOTGUN

Pursuant to Sec. 134-2(f) Hawaii Revised Statutes (as amended 1994), you are hereby informed of the following transaction:

BUYER/TRANSFEREE _______________________

ADDRESS _________________________________

PERMIT TO ACQUIRE # ______________________    EXP. DATE __________________

MAKE             : _____________________________

MODEL          : _____________________________

CALIBER:      : _____________________________

TYPE OF ACTION    : _______________________________

SERIAL NUMBER    : _______________________________

__________________________________
PRINT NAME OF SELLER/TRANSFEROR

__________________________________
 SIGNATURE OF SELLER/TRANSFEROR

_____________________
             DATE              

VENDOR/TRANSFEROR SHALL SIGN IN INK AND DELIVER TO THE POLICE STATION PERSONALLY OR BY REGISTERED MAIL WITHIN 48 HOURS.

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