PISTOL LICENSE APPLICATION GUIDE 643 041 Hand Gun Forms
User Manual: 643-041
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INSTRUCTIONS TO HANDGUN LICENSE APPLICANTS PD 643-115 (Rev. 02-15) POLICE DEPARTMENT CITY OF NEW YORK HANDGUN LICENSE APPLICATION SECTION LICENSE DIVISION ROOM 110A INSTRUCTIONS TO ALL HANDGUN LICENSE APPLICANTS The attached application MUST be typewritten and signed. Only the original application will be accepted. DO NOT SUBMIT A PHOTOCOPY. The application must be completely filled out and presented by you personally at the License Division. At the time you submit your application, you must furnish the items listed below that are applicable to you. You must submit original copies of certificates, licenses, etc. In addition, a legible photocopy of each item submitted must accompany the original or certified copy. (A copy certified by the issuing agency as true and complete is also acceptable in lieu of the original.) Your application will not be accepted without producing the required documents. 1. Fees. Two (2) separate fees are required. These are payable by certified check, bank check, money order or credit card. All fees are non-refundable. – $340.00 - Made payable to New York City Police Department – $ 89.75 - Made payable to New York City Police Department 2. Photographs. Two (2) recent color photographs of yourself. They should measure 1½ x 1½ inches and show you from the chest up. Do not wear any article of clothing or adornment that obscures your facial features. 3. Birth Certificate. In lieu of your birth certificate, some other proof of your birth date, e.g., a military record, U.S. passport or baptismal certificate, must be submitted. 4. Proof of Citizenship/Alien Registration. If you were born outside the United States, you must submit your naturalization papers or evidence of citizenship if derived from your parents. All other applicants born outside the United States must submit their Alien Registration Card. If you have lived in this country less than 7 years you must submit a good conduct certificate from your country of origin. 5. Military Discharge. If you served in the armed forces of the United States, you must submit your separation papers (DD 214) and your discharge. 6. Proof of Residence. You must submit proof of your present address. Proof may consist of, but is not limited to, a real estate tax bill, ownership shares in a cooperative or condominium, or a lease. You may also be requested to supply further documentation, i.e., a New York State Driver’s License, a New York State Income Tax Return, a Utility Bill, etc. 7. A.) Arrest Information: If you were ever arrested, indicted or summonsed (other than parking violations) for any reason you must answer Yes to question-23 and submit a certificate of disposition showing the offense and the disposition. Also, you must submit a detailed statement describing the circumstances surrounding each arrest. YOU MUST DO THIS EVEN IF: the case was dismissed, the record sealed or the case nullified by operation of law. The New York State Division of Criminal Justice Services will report to us every instance involving the arrest of an applicant. DO NOT rely on anyone’s representation that you need not list a previous arrest because it was sealed. If you were ever convicted or pleaded guilty to a felony, or a serious offense as defined in Penal Law Section 265.00(17), an original Certificate of Relief from Disabilities must be submitted. B.) Summons Information: If you have received a summons for other than a parking violation you must answer Yes to question-23. You must list the violation and disposition for each summons received. C.) Order of Protection: If you have ever had an Order of Protection or Restraining Order issued against you, or issued on your behalf against anyone, you must list the following information: Court of Issuance; Complainant’s or Respondent / Defendant’s name, including address and phone number; Complainant’s or Respondent / Defendant’s relationship to you; Reason for issuance of Order of Protection or Restraining Order. 8. Proof of Business Ownership. If you are making application for a License in connection with a business, you must submit proof of ownership for that business. Such proof must clearly state the names of the owner(s), or, if a corporation, the names of the corporate officers. A corporation must submit its corporate book including filing receipt, certificate of incorporation and minutes of the corporate meeting reflecting current corporate officers; others must provide their business certificate or partnership agreement, whichever is applicable. If the business requires a license or permit from any government agency, e.g. alcohol or firearms sales, gunsmith, private investigation and guard agencies, you must submit the license or permit or a certified copy thereof. You must submit proof of address for the business. Proof may consist of a utility bill, not more than 60 days old, in the name of the business or a lease in the name of the business. 9. Letter of Necessity. All applicants for a carry license and those seeking a premise license for use in connection with their employment MUST complete the Letter of Necessity found on page 3 of the application. NO SUBSTITUTES WILL BE ACCEPTED. 10. You must bring your original social security card when you apply. If you have any questions concerning your application, please call (646) 610-5551. Applications must be submitted in person at the License Division, One Police Plaza Room 110, New York, NY or the Rifle / Shotgun Section, 120-55 Queens Blvd. Rm. B11, Kew Gardens, NY. The License Division’s hours of operation are: Monday thru Friday between the hours of 8:30 a.m. to 4:00 p.m. Applicants must arrive early enough for processing to be completed by the close of business. http://nyc.gov/html/nypd/html/permits/handgun_licensing_application.shtml Photo taken within 30 days prior to date of application. HANDGUN LICENSE APPLICATION FRONT VIEW 1½ x 1½ Square LICENSE DIVISION POLICE DEPARTMENT CITY OF NEW YORK OFFICIAL USE ONLY PD 643-041 (Rev. 11-10) 1 POLICE PLAZA NEW YORK, N.Y. 10038 NYSID NUMBER All applications must be typewritten. DO NOT MAKE ENTRIES IN SHADED AREAS. Necessary fee must accompany application. Make Bank Check, Certified Check or Money Order payable to the Police Department, City of New York. Payment may also be made by credit card. Not refundable if application is disapproved. (Administrative Code Sec. 10-131) DATE APPLICATION NUMBER SECTION A TO BE ANSWERED BY ALL APPLICANTS CARRY BUSINESS CARRY GUARD/SECURITY RETIRED POLICE OFFICER LIMITED CARRY GUN CUSTODIAN PREMISES (Indicate Residence Business) SPECIAL (out of city validation.) CARRY LICENSE NUMBER (Renewal Applicant) 1. Last Name 3 Citizen Do you possess any other NYC Handgun Lic.? If YES TYPE LIC. NO. YEAR First Name M.I. 2. Legal Address (Street No.) Apt. # Alien Registration Number OLD LICENSE NUMBER Complaint No. Lost Mutilated Corp Code Cust Code Maiden Name/Alias City or Town State Social Security Number Zip Code Res. Pct. OCC Code Total Guns Code Color of Hair Color of Eyes Alien Home Phone No. Cell Phone No. 4. Place of Birth - City, State, Country Email Address Age Date of Birth Hgt. (inches) Wgt. Sex EMPLOYMENT INFORMATION 5. Name of Business Type of Business 6. Business Address (Street No.) 7. Bus. Telephone No./Day Bus. Pct. City or Town Occupation (Owner - Employee - Gun Custodian) State Zip Code How many other persons in this business have N.Y.C. Handgun Licenses? 8. If applicable, list name, job title and license number of company gun custodian VALIDATION OF OUT OF CITY LICENSE (Special Handgun License ONLY) 9. Basic License Number Issued By County Date Issued Expiration Date LIST HANDGUNS FOR THIS APPLICATION ONLY 10. (ORIGINAL APPLICANT LEAVE BLANK) MAKE MODEL GUN SERIAL NUMBER CALIBER TYPE OWNER R Revolver A Automatic E Employer S Self MAKE CODE 001 002 OFFICIAL USE ONLY Right Thumb NOTICE Pursuant to Penal Law Section 400.00(5), the name and address of any person to whom an application for any license has been granted, shall be a public record. SIGNATURE OF PERSON PRINTED 1 of 5 SECTION B Applicants must answer questions 10 through 24. Additionally questions 29 through 31 must be answered chronologically and in detail. If you have answered YES to question(s) 10 through 28 you MUST use the HANDGUN LICENSE APPLICATION ADDENDUM (PD 643-041A ) to explain such answer(s) in complete detail. A FALSE STATEMENT SHALL BE GROUNDS FOR DENIAL OF A N.Y.C. HANDGUN LICENSE HAVE YOU EVER... 10. Had or ever applied for a Handgun License issued by any Licensing Authority in N.Y.S.? ......................... Yes No 11. Been discharged from any employment? .................................................................................................... Yes No 12. Used narcotics or tranquilizers? List doctor’s name, address, telephone number, in explanation. ............ Yes No 13. Been subpoenaed to, or testified at, a hearing or inquiry conducted by any executive, legislative or judicial body? ......................................................................................................................... Yes No 14. Been denied appointment in a civil service system, Federal, State, Local? ............................................... Yes No 15. Served in the armed forces of this or any other country? ............................................................................ Yes No 16. Received a discharge other than honorable? .............................................................................................. Yes No 17. Been rejected for military service? .............................................................................................................. Yes No 18. Are you presently engaged in any other employment, business or profession where a need for a firearm exists? ............................................................................................................................................ Yes No 19. Had or applied for any type of license or permit issued to you by any City, State or Federal agency? ...... Yes No 20. Has any corporation or partnership of which you are an officer, director, or partner, ever applied for or been issued a license or permit issued by the Police Dept? Give type, year, license number, in explanation. .......... Yes No 20a. Has any officer, director or partner ever applied for or been issued a license or permit issued by the Police Department? Give type, year, license number, in explanation. .................................................. Yes No 21. Suffered from mental illness, or due to mental illness received treatment, been admitted to a hospital or institution, or taken medication? List Doctor’s/Institutions, Name, Address, Phone #, in explanation .. Yes No 22. Have you ever suffered from any disability or condition that may affect your ability to safely possess or use a handgun? List Doctor’s Name, Address, Phone #, in explanation. ................................ Yes No NOTE: The following conditions must be listed: Epilepsy, Diabetes, Fainting Spells, Blackouts, Temporary Loss of Memory or any Nervous Disorder. Before answering questions number 23 thru 26, read paragraph 7 of the instructions completely. 23. Been arrested, indicted, or summonsed for ANY offense other than Parking Violations, in ANY jurisdiction, federal, state, local or foreign? You must include cases that were dismissed and/or the record sealed. List the following: date, time, charge(s),disposition, court and police agency. (False statements are grounds for disapproval). .......................................................................................... Yes No 24. Have you ever, or do you now have an Order of Protection issued against you? ........................................ Yes No 25. Have you ever, or do you now have an Order of Protection issued by you against a member of your household, or any family member? ............................................................................................................. Yes No 26. Have you ever, or do you now have an Order of Protection issued by you against a person other than a member of your housold or family? .......................................................................................................... Yes No If you have answered yes to questions 24 - 26, you must indicate the following information: a. Court of Issuance b. Date of Issuance c. Complainant’s Name, Address and Telephone Number d. Complainant’s relationship to you e. Reason for issuance of Order of Protection 27. Have the police ever responded to a domestic incident in which you were involved? .................................. Yes No 28. Used any variation in spelling of your name or any other name used? (Alias), explain. ............................. Yes No 2 of 5 LIST ALL PLACES OF RESIDENCE FOR PAST FIVE (5) YEARS FROM TO (MONTH AND YEAR) 29. PRECINCT RESIDENCE (Include State, County, Zip Code and Apt. No.) PRESENT FROM TO (MONTH AND YEAR) LIST ALL PLACES OF EMPLOYMENT FOR PAST FIVE (5) YEARS BUSINESS NAME AND ADDRESS (Include State, County, Zip Code and Apt. No.) OCCUPATION PRECINCT PRESENT 30. How and where will handgun(s) be safeguarded when not in use? (Location outside of N.Y. State is unacceptable). 31. Give name, address, relation and telephone number of person who will safeguard handgun(s) in case of applicant’s death or disability. Must be a N.Y. State resident. The undersigned affirms that the statements made and answers given herein are accurate and complete, and hereby authorizes the New York City Police Department, License Division to make appropriate inquiries in connection with processing this application. False written statements in this document are punishable under Section 210.45 of the New York Penal Law (making a punishable false written statement) and also will be sufficient cause for denial of an application, license or permit by the New York City Police Department, License Division. Date __________________________ Signature ______________________________________________________________ INVESTIGATING OFFICER’S SIGNATURE DATE TAX REGISTRY NO. APPROVAL DISAPPROVAL and REASON SUPERVISOR’S SIGNATURE DATE TAX REGISTRY NO. APPROVAL DISAPPROVAL and REASON C.O. INVEST. SECTION SIGNATURE DATE TAX REGISTRY NO. APPROVAL DISAPPROVAL and REASON C.O. LICENSE DIVISION SIGNATURE DATE TAX REGISTRY NO. APPROVAL DISAPPROVAL and REASON 3 of 5 ADDITIONAL INSTRUCTIONS FOR CARRY LICENSE APPLICANTS LETTER OF NECESSITY All applicants for a carry license for use in connection with a business or profession must answer the following questions in the space provided. If additional space is necessary continue your letter on reverse side. In ALL CASES the form provided must be used. 1. A detailed description of the applicant’s employment and an explanation of why the employment requires the carrying of a concealed handgun. 2. A statement acknowledging that the handgun may only be carried during the course of and strictly in connection with the applicant’s job, business or occupational requirements, as described herein. 3. A statement explaining the manner in which the gun will be safeguarded by the employer and/or applicant when not being used. 4. A statement indicating that the applicant has been trained or will receive training in the use and safety of a handgun. 5. A statement acknowledging that the applicant’s employer, or, if self employed, the applicant, is aware of its or his or her responsibility to properly dispose of the handgun and return the license to the License Division upon the termination of the applicant’s employment or the cessation of business. 6. A statement indicating that the applicant, and if other than self employed, a corporate officer, general partner, or proprietor, has read and is familiar with the provisions of Penal Law Articles 35 (use of deadly force), 265 (criminal possession and use of a firearm) and 400 (responsibilities of a handgun licensee). The Letter of Necessity is part of this application. Any false statement is an offense punishable as a Class A Misdemeanor pursuant to to Section 210.45 of the New York State Penal Law. The undersigned affirms that the statements made and answers given herein are accurate and complete, and hereby authorizes the New York City Police Department, License Division to make appropriate inquiries in connection with processing this application. False written statements in this document are punishable under Section 210.45 of the New York Penal Law (making a punishable false written statement) and also will be sufficient cause for denial of an application, license or permit by the New York City Police Department, License Division. Date __________________________ Signature ______________________________________________________________ 4 of 5 ADDITIONAL DOCUMENTATION TO BE PRESENTED AT PERSONAL INTERVIEW At the time of your interview, you must also furnish the following documents, as they apply to you: 1. The two (2) most recent copies of the business’s sales tax report (ST 100) submitted to the State of New York and Federal Tax Return submitted for the previous year. If the business is solely a wholesale operation, a copy of the Federal tax return submitted for the previous tax year must be submitted. All tax forms must bear notarized signatures. 2. When requested by your investigator, your personal income tax return for the previous tax year. 3. Daily bank deposit slips and corresponding bank statements for the six months preceding the date of your interview. (Photocopies will not be accepted.) 4. A statement from your bank setting forth the total amount of your payroll and the total amount of payroll checks cashed during the three months immediately preceding the date of your interview. 5. If you were the victim of a crime which occurred during the course of your business or professional activities during the previous two years, you must provide the complaint report number, date and the precinct of occurrence. At the time of your interview, your investigating officer will advise you if any additional forms or documents are required. NOTICE TO ALLAPPLICANTS: While the application is pending, the applicant shall make an immediate report to the License Division, Applicant Section at (646) 610-5551, of any of the following occurrences: 1. Arrest, indictment, or conviction in any jurisdiction; summons other than traffic infraction; suspension or ineligibility order issued pursuant to section 530.14 of the New York State Criminal Procedure Law or Section 842-a of the New York State Family Court Act. 2. Change of business or residence address. 3. Change of business, occupation or employment. 4. Any change in the circumstances cited by the applicant in their application. 5. Receipt of psychiatric treatment or treatment for alcoholism or drug abuse, or the presence or occurence of any disability or condition that may affect the ability to safely possess or use a handgun. 6. Applicant is or becomes the subject or recipient of an Order of Protection or a Temporary Order of Protection. The applicant may be required to provide additional documentation for any of the above occurrences to License Division personnel. 5 of 5 HANDGUN LICENSE APPLICATION ADDENDUM PD 643-041A (11-10) This form is to be used to provide a detailed explanation for any “yes” answers to questions 10 through 28 on the HANDGUN LICENSE APPLICATION (PD 643-041). This form may be reproduced if necessary. Question Number Detailed Explanation The undersigned affirms that the statements made and answers given herein are accurate and complete, and hereby authorizes the New York City Police Department, License Division to make appropriate inquiries in connection with processing this application. False written statements in this document are punishable under Section 210.45 of the New York Penal Law (making a punishable false written statement) and also will be sufficient cause for denial of an application, license or permit by the New York City Police Department, License Division. Date __________________________ Signature ______________________________________________________________ NEW YORK CITY CHARTER CHAPTER 18-C: PUBLIC SAFETY* NYC Charter § 460 § 460 Gun-free school safety zones. a. It shall be a crime for any individual knowingly to possess a firearm at a place that the individual knows, or has reasonable cause to believe, is a school zone. b. Subdivision a of this section shall not apply where the firearm is: (i) possessed and kept in such individual's home in a school zone, provided that such individual is licensed or permitted to possess such firearm; or (ii) possessed and kept at such individual's business in a school zone, provided that such individual is licensed or permitted to possess such firearm. c. Affirmative defenses to the crime established in subdivision a shall include possession of a firearm: (i) carried for personal safety between such individual's business, home, or bank in a school zone, provided that such individual is licensed or permitted to possess such firearm for such purpose; (ii) just purchased or obtained by such individual and being transported that same day for the first time to such individual's home or business in a school zone where it will be stored, provided that such individual is licensed or permitted to possess such firearm; (iii) carried between a police department facility for inspection and an individual's business, home, bank, or point of purchase in a school zone, provided that such individual is licensed or permitted to possess such firearm; (iv) carried by licensed or permitted individuals and being transported to or from an authorized target practice facility; (v) carried between a gunsmith for demonstrably needed repairs and an individual's business or home in a school zone, provided that such individual is licensed or permitted to possess such firearm; (vi) used in an athletic or safety program approved by a school in a school zone, or by the police commissioner, or in accordance with a contract entered into between a school within the school zone and the individual or an employer of the individual, provided that such individual is licensed or permitted to possess such firearm for such purpose; or (vii) used in accordance with a contract entered into between a business within the school zone and the individual or an employer of the individual, provided that such individual is licensed or permitted to possess such firearm for such purpose. d. It shall be a crime for any person, knowingly or with reckless disregard for the safety of another, to discharge a firearm in a school zone. e. Affirmative defenses to the crime established in subdivision d shall include discharge of a firearm: (i) by an individual for self-defense, provided that such individual is licensed or permitted to possess such firearm for such purpose; (ii) for use in a special event or safety program authorized by a school in a school zone or by the police commissioner; (iii) by an individual in accordance with a contract entered into between a school in the school zone and the individual or an employer of the individual, provided that such individual is licensed or permitted to possess such firearm for such purpose; or (iv) by an individual in accordance with a contract entered into between a business and the individual or an employer of the individual, provided that such individual is licensed or permitted to possess such firearm for such purpose. f. Any person who violates this section shall be guilty of a misdemeanor, punishable by imprisonment of not more than one year or by a fine of not more than ten thousand dollars, or both. g. In addition to the penalties prescribed in subdivision f of this section, any person who violates this section shall be liable for a civil penalty of not more than ten thousand dollars. h. This section shall not apply to a police officer, as such term is defined in section 1.20 of the criminal procedure law, or a federal law enforcement officer, as such term is defined in section 2.15 of the criminal procedure law. i. The police commissioner may promulgate rules implementing the provisions of this section. The police commissioner shall provide written notice of the requirements of this section to all persons who receive an official authorization to purchase a firearm and to all persons applying for a license or permit, or renewal of a license or permit. Failure to receive such notice shall not be a defense to any violation of this section. j. The city of New York and its agencies, officers or employees shall not be liable to any party by reason of any incident or injury occurring in a gun-free school safety zone arising out of a violation of any provision of this section. Page 1 NEW YORK CITY CHARTER CHAPTER 18-C: PUBLIC SAFETY* NYC Charter § 459 § 459 Definitions. a. The term "school" means a public, private or parochial, day care center or nursery or pre-school, elementary, intermediate, junior high, vocational, or high school. b. The term "school zone" means in or on or within any building, structure, athletic playing field, playground or land contained within the real property boundary line of a public, private or parochial day care center or nursery or preschool, elementary, intermediate, junior high, vocational, or high school, or within one thousand feet of the real property boundary line comprising any such school. c. The term "firearm" means a firearm, rifle, shotgun, or assault weapon, as such terms are defined in section 10301 of the administrative code, or a machine gun, as defined in penal law section 265.00. HISTORICAL NOTES: Section added at General Election, November 6, 2001 (Question 3 § 1) eff. immediately upon certification that electors have approved the amendments. TYPES OF LICENSES PREMISES LICENSE: ISSUED FOR YOUR RESIDENCE OR BUSINESS, THIS IS A RESTRICTED TYPE OF LICENSE. The Licensee may possess a handgun at the specific location indicated on the front of the license. This license permits the transporting of an unloaded handgun directly to and from an authorized small arms range/shooting club, secured unloaded in a locked container. Ammunition must be carried separately. CARRY BUSINESS LICENSE: IS VALID FOR THE BUSINESS NAME, ADDRESS, AND FIREARM(S), LISTED ON THE FRONT OF THE LICENSE. IT IS NOT TRANSFERABLE TO ANY OTHER PERSON, BUSINESS, OCCUPATION, OR ADDRESS, WITHOUT THE WRITTEN APPROVAL OF THE COMMANDING OFFICER, LICENSE DIVISION. LIMITED CARRY BUSINESS LICENSE: IS A RESTRICTED LICENSE. THE LICENSEE MAY ONLY CARRY THE FIREARM INDICATED ON THE LICENSE IN ACCORDANCE WITH THE SPECIFIC LIMITATIONS LISTED THEREON. AT ALL OTHER TIMES THE WEAPON MAY BE POSSESSED ONLY WITHIN THE CONFINES OF THE BUSINESS ADDRESS LISTED ON THE FRONT OF THE LICENSE. SPECIAL CARRY LICENSE: IS VALID FOR THE BUSINESS NAME, ADDRESS AND FIREARMS(S) LISTED ON THE FRONT OF THIS LICENSE ONLY WHILE THE LICENSEE HAS IN HIS POSSESSION HIS VALID BASIC COUNTY LICENSE ISSUED ACCORDING TO THE PROVISIONS OF ARTICLE 400 OF THE N.Y.S. PENAL LAW. UPON THE REVOCATION, SUSPENSION, OR CANCELLATION OF THE BASIC LICENSE, THE SPECIAL LICENSE IS RENDERED VOID AND MUST BE IMMEDIATELY RETURNED TO THE LICENSE DIVISION. RESTRICTED CARRY LICENSE (SECURITY GUARDS, ETC.): APPLICATIONS FOR THIS TYPE OF LICENSE MUST BE MADE WITH THE DOCUMENTATION PROVIDED BY THE COMPANY’S “GUN CUSTODIAN”. IT IS ISSUED ONLY FOR THE FIREARM LISTED ON THE LICENSE. THE FIREARM MAY BE CARRIED ONLY WHILE THE LICENSEE IS ACTIVELY ENGAGED IN EMPLOYMENT. AT ALL OTHER TIMES THE FIREARM MUST BE STORED UNLOADED IN A LOCKED CONTAINER AT EITHER THE ADDRESS ON THE LICENSE OR AT THE EMPLOYEE’S LEGAL RESIDENCE (WITHIN THE STATE OF NEW YORK). For information concerning “Gun Custodian” licenses, “Dealers in Firearms” licenses, or “Gunsmith” licenses you may contact the License Division’s Gun Custodian Section at 646-610-5936 PERSONS PROHIBITED FROM POSSESSING FIREARMS TITLE 18, UNITED STATES CODE, SECTION 922g ANYONE UNDER INDICTMENT FOR A CRIME FOR WHICH THEY COULD BE IMPRISONED FOR MOR THAN ONE YEAR. ANYONE CONVICTED OF A CRIME FOR WHICH THEY COULD HAVE BEEN IMPRISONED FOR MORE THAN ONE YEAR. ANYONE WHO IS AN UNLAWFUL USER OF MARIJUANA, NARCOTICS OR ANY CONTROLLED SUBSTANCE. ANYONE WHO HAS BEEN ADJUDICATED MENTALLY DEFECTIVE OR INVOLUNTARILY COMMITTED TO A MENTAL INSTITUTION. ANYONE DISHONORABLY DISCHARGED FROM THE ARMED FORCES. ANYONE IN THE UNITED STATES ILLEGALLY. ANYONE SUBJECT TO A COURT ORDER RESTRAINING THEM FROM HARASSING, STALKING OR THREATENING AN INTIMATE PARTNER OR CHILD OF A PARTNER. ANYONE CONVICTED OF A MISDEMEANOR CRIME OF DOMESTIC VIOLENCE. A PROHIBITED PERSON CANNOT RECEIVE OR POSSESS A FIREARM. A LICENSED DEALER MAY NOT TRANSFER A FIREARM TO ANYONE THEY HAVE CAUSE TO BELIEVE IS PROHIBITED. THESE ARE VIOLATIONS OF FEDERAL LAW AND MAY RESULT IN FINES OR IMPRISONMENT OF UP TO 10 YEARS. REQUEST FOR PRE-LICENSE EXEMPTION Pistol License Applicant: If you wish to request consideration for a pre-license exemption, you must complete this form and return it to the License Division at the time you file your application for a handgun license. Your request will be reviewed after an investigation is conducted to determine if you have a previous criminal record. A determination to approve or disapprove your request will be made at that time. Approval of your request will authorize you to shoot at an appropriate range while your application for a handgun license is under investigation. This exemption terminates if your application for a license is denied or at any earlier time based on information which would result in the denial of your application. Commanding Officer License Division _________________________ Applicant’s Name ____________________________________ Application Control Number __________________________________________________________________________________________ Applicant’s Address _______ Age _______________ Birth Date _____________________________________ Name of Range, Address, Telephone Number ________________________ Type of License ________________________ Name of Instructor Instructor’s Verified Statement: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________ Applicant’s Signature _______________________ Instructor’s Signature THIS FORM MUST BE TYPED AND NOTARIZED AFFIRMATION OF FAMILIARITY WITH RULES AND LAW (38 RCNY 5-33) License number ___________________________________ The undersigned affirms and acknowledges that he/she has knowledge of and shall be responsible for compliance with all laws, rules, regulations, standards and procedures promulgated by federal, state, or local jurisdictions, and by federal, state, or local law enforcement agencies that are applicable to this license. False written statements in this document are punishable under Section 210.45 of the New York Penal Law (making a punishable false written statement) and also will be sufficient cause for denial of an application, license or permit by the New York City Police Department, License Division. Date________________ Signature______________________________________ Print name_____________________________________ MISC 4419 (REV 05-12) Affidavit of Co-Habitant State of New York County of ss.: I, , residing at (Name of person making affidavit) (Address, including zip code) in the City of New York, do hereby affirm that the applicant, , (Name of applicant) currently resides with me at the above address. My relationship to the applicant is . (Nature of relationship) My telephone number is (H) (C) (W) I understand that the applicant has applied for a rifle/shotgun permit or handgun license from the New York City Police Department, and I have no objection to him/her receiving a permit or license and storing firearms in my home. (Signature) Sworn to before me this day of Notary Public Revised 9/25/2009 New York City Police Department License Division One Police Plaza New York, NY 10038 (646) 610-5560 Date: Application # Name: Investigator: Acknowledgement of Person Agreeing to Safeguard Firearm(s) Detective Olmo Name of Applicant / Licensee: ______________________________________________ Application / License Number:_______________________________________________ Instruction to Applicant / Licensee: Please ask the person you have designated to safeguard and surrender your firearm(s) in the event of your death or incapacity to complete the information below and sign this acknowledgement before a witness. (The person you designate must be a New York State resident.) Print Name: ____________________________ ________________________ ______ Last First M.I. Address: __________________________ ____ _______________ NY _________ Number & Street Name Telephone Numbers: _________________________ Home Apt City State Zip _____________________________ __________________________ Cell Business I,____________________________________________________________________ (Print name of person agreeing to safeguard firearms) understand that the above-named applicant/licensee has designated me to safeguard and surrender his/her firearm(s) in the event that he/she dies or becomes incapacitated. I agree that upon learning of the death or incapacity of the licensee, I will immediately notify the New York City Police Department’s License Division at (646) 610-5871 or (646) 610-5560, or by calling the local police precinct, and will follow their directions to safeguard and surrender his/her firearm(s). Signature of person agreeing to safeguard firearm(s): _____________________________________ Date:__________ Witnessed by (signature) ______________________________________ Witness’ name (printed) ______________________________________ Please retain a copy of this document for your records NYPD Safeguard Firearms letter May 2010 NYS Firearms License Request for Public Records Exemption Pursuant to section 400.00 (5) (b) of the NYS Penal Law I am: [ ] an applicant for a firearms license [ ] currently licensed to possess a firearm in NYS Name ____________________________________________ Date of Birth_____________________ Address_________________________________________ City_________________ State________ Firearms License # (if applicable) ____________________________ Date Issued________________ Licensing Authority / County of Issuance or Application _____________________________________ I hereby request that any information concerning my firearms license application or firearms license not be a public record. The grounds for which I believe my information should NOT be publicly disclosed are as follows: (check all that are applicable) [ ] 1. My life or safety may be endangered by disclosure because: [ ] A. I am an active or retired police officer, peace officer, probation officer, parole officer, or corrections officer; [ ] B. I am a protected person under a currently valid order of protection; [ ] C I am or was a witness in a criminal proceeding involving a criminal charge; [ ] D. I am participating or previously participated as a juror in a criminal proceeding, or am or was a member of a grand jury; [ ] 2. My life or safety or that of my spouse, domestic partner or household member may be endangered by disclosure for some other reason explained below: (Must be explained in item 5 below) [ ] 3. I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1. (Please check any that apply) A _____ B_____ C_____ D_____ [ ] 4. I have reason to believe that I may be subject to unwarranted harassment upon disclosure. 5. (Please provide any additional supportive information as necessary) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ I understand that false statements made herein are punishable as a class A misdemeanor. I further understand that upon discovery that I knowingly provided any false information, I may be subject to criminal penalties and that this request for an exemption shall become null and void. _____________________________________________________ Signature ________________________ Date
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