Reference Collection Receipt Version 3 North Carolina State Crime Laboratory Effective Date: 1/7/2019 Physical Evidence Section –

FIREARMS REFERENCE COLLECTION RECEIPT

Submitting Agency: ______Date: ______

FR # Assigned: Keep Destroy Condition: G F P S/O (Sawed off)

Firearm Type: Revolver Other

Semi Full Swing Break Pump/ : Pin Lever Bolt Air/CO2 Multi Barrel (____) Auto Auto Out Open Slide

Manufacturer: Model:

Caliber: Serial Number:

Safety Check upon Receipt: ☐ Check on Entry to Collection: ☐

FR # Assigned: Keep Destroy Condition: G F P S/O (Sawed off)

Firearm Type: Pistol Revolver Derringer Rifle Shotgun Other

Semi Full Swing Break Pump/ Action: Pin Lever Bolt Air/CO2 Multi Barrel (____) Auto Auto Out Open Slide

Manufacturer: Model:

Caliber: Serial Number:

Safety Check upon Receipt: ☐ Safety Check on Entry to Collection: ☐

FR # Assigned: Keep Destroy Condition: G F P S/O (Sawed off)

Firearm Type: Pistol Revolver Derringer Rifle Shotgun Other

Semi Full Swing Break Pump/ Action: Pin Lever Bolt Air/CO2 Multi Barrel (____) Auto Auto Out Open Slide

Manufacturer: Model:

Caliber: Serial Number:

Safety Check upon Receipt: ☐ Safety Check on Entry to Collection: ☐

FR # Assigned: Keep Destroy Condition: G F P S/O (Sawed off)

Firearm Type: Pistol Revolver Derringer Rifle Shotgun Other

Semi Full Swing Break Pump/ Action: Pin Lever Bolt Air/CO2 Multi Barrel (____) Auto Auto Out Open Slide

Manufacturer: Model:

Caliber: Serial Number:

Safety Check upon Receipt: ☐ Safety Check on Entry to Collection: ☐

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