Putnam Pistol Permit Application Assistance

Putnam County Information

Last Name

First Name

Middle Name

Maiden Name

Alias (i.e., previous married name or a/k/a)

Address

Mailing Address (if different)

Previous Address (If less than10 years at your present address)

Have your esided in Putnam County for at least 6 months?
NoYes

Home Phone

Cell Phone

Date of Birth

Age

Sex
FM

Height (feet/inches)

Weight (pounds)

Eye Color (do not abbreviate)

Hair Color (do not abbreviate)

Race (White,Black,Asian,Native American)

Ethenicity (Hispanic,Non-Hispanic,Other)

Are You a United States Citizen?
---NoYes

Social Security Number (numbers only)

NYS Driver's License Number

State of Birth

Country of Birth (If other than US)

Alien Registration Number (if applicable)

Current Employer (Do not leave blank.State if you are retired, unemployed, homemaker, student, disabled, etc.)

Employer Address

Putnam_Occupation (i.e.,Teacher)

Nature of Employment (i.e., Education)

Business Phone Number

TYPES OFCARRY LICENSES
Hunting and Target—Firearm may be carried at an authorized range or while actually hunting in a legal area inNew York State or traveling there to and there from. For hunting you must also possess a valid NewYorkState hunting license.
Sportsperson—Firearm maybe carried while actually engaged in the sport related activities of Target Shooting, Hunting, Hiking,Camping and Fishing, or traveling there to and there from.
BusinessPurposes—Firearm may only be carried while actually engaged in conducting business for which the license was issued or traveling directly there to or there from.
UnrestrictedCarry—You must be a police officer or peace officer(active or retired) or you must show "additional proper cause" to qualify for this endorsement. "Additional proper cause" is determined by a review of all relevant information of your claimed need, and generally is established by demonstrating a need forself-protection distinguishable from that of the general community or other circumstances justifying the granting of an unrestricted license.

Type of License You are Applying for
---Business PurposesSportspersonHunting and TargetUnrestricted Carry

Give four (4) character references who,by their signature, attest to your good moral character. Each character reference must be 21 years of age or older. Each reference must personally sign the form.

Reference 1 Name

Reference 1 Street

Reference 1 City, State, Zipcode

Reference 2 Name

Reference 2 Street

Reference 2 City, State, Zipcode

Reference 3 Name

Reference 3 Street

Reference 3 City, State, Zipcode

Reference 4 Name

Reference 4 Street

Reference 4 City, State, Zipcode

Have you ever been arrested, summoned, charged or indicted anywhere for any offense, includingDWI (except traffic infractions)?
NoYes

If yes, furnish the following information. Information MUST be complete. Dispositions MUST be provided.

Disposition Date

Disposition Police Agency

Disposition Charge

Disposition

Disposition Court and Date

Disposition Date 1

Disposition Police Agency 1

Disposition Charge 1

Disposition 1

Disposition Court and Date 1

Disposition Date 2

Disposition Police Agency 2

Disposition Charge 2

Disposition 2

Disposition Court and Date 2

Disposition Date 3

Disposition Police Agency 3

Disposition Charge 3

Disposition

Disposition Court and Date 3

Disposition Date 4

Disposition Police Agency 4

Disposition Charge 4

Disposition 4

Disposition Court and Date

Disposition Date 5

Disposition Police Agency 5

Disposition Charge 5

Disposition 5

Disposition Court and Date

Have you ever been terminated/discharged from any employment or the armed forces for cause?
NoYes

Are you a fugitive from justice?
NoYes

Have you ever renounced your citizen ship to the United States of America?
NoYes

Have you ever undergone treatment for alcoholism or drug use?
NoYes

Have you ever suffered any mental illness, or been confined to any hospital,public or private institution, for mental illness or have you had a guardian appointed because of a lack of mental capacity?
NoYes

Have you ever had a pistol license, dealer's license, gunsmith license, or any application for such a license disapproved, or had such a license revoked or cancelled?
NoYes

Do you have any physical condition which could Interfere with the safe and proper use of a handgun?
NoYes

Have you ever been charged, petitioned against, a respondent, or otherwise been a subject of a proceeding in family court?
NoYes

If answer to any question is YES, explain here:

Explanation

Explanation

Explanation

Explanation

Explanation

New York State Information:

Last Name

First Name

Middle Initial

Suffix

Date of Birth

NYS Drivers License Number

Gender (Male or Female)

Social Security Number (numbers only)

Race

Weight

Height

Eye Color

Hair Color

Citizen of USA?
NoYes

Physical Address (Street number, street name, apartment number., city, state, zipcode)

Mailing Address (If different from physical address)

Primary Phone

Secondary Phone

E-Mail Address

Employed By

Present Occupation

Nature of Business

NYS-EmployerAddress

I here by apply for a Pistol Revolver License to: (Check only one)
CarryPremisesBusiness

Premise Address or Employer Name and Address must be provided below:

Employer Name (If Carry During Employment)

Employer Address or Other Location (Street number, street name, apartment number, city, state, zipcode)

Give four character references who by their signature attest to your good moral character:

Reference Name #1 (Last, First, MI)

Reference Address #1 (Street number, street name, apartment number, city, state, zipcode)

Reference Name #2

Reference Address #2 (Street number, street name, apartment number, city, state, zipcode)

Reference Name #3

Reference Address #3 (Street number, street name, apartment number, city, state, zipcode)

Reference Name #4

Reference Address #4 (Street number, street name, apartment number, city, state, zipcode)

Have you ever been arrested, summoned, charged, or indicted anywhere for any offense, including DWI(except traffic infractions)?
NoYes

If YES, furnish the following information:

Arrest Date 1

Police Agency 1

Charge 1

Disposition Date 1

Disposition Court 1

Disposition 1

Arrest Date 2

Police Agency 2

Charge 2

Disposition Date 2

Disposition Court 2

Disposition Date 2

Are you a fugitive from Justice?
NoYes

Are you an unlawful user of or addicted to any controlled substance as defined In section 21 U.S.C. 802?
NoYes

Are you an alien illegally or unlawfully In the United States?
NoYes

Are you an alien admitted to the United States who does not qualify for the exceptions under 18 U.S.C. 922(y)(2)?
NoYes

Have you been discharged from the Armed Forces under dishonorable conditions?
NoYes

Have you ever renounced your United States citizenship?
NoYes

Have you ever suffered any mental illness?
NoYes

Have you ever been involuntarily committed to a mental health facility?
NoYes

Have you ever had a pistol / revolver license revoked?
NoYes

Are you under any firearms suspension or in eligibility order issued pursuant to the provisions of section 530.14 of thecriminal procedure law or section eight hundred forty-two-a of the family court act?
NoYes

Haveyou had a guardian appointed for you pursuant to any provision of state law, based on a determination that as a result of marked subnormal Intelligence, mentalIllness, incapacity, condition or disease you lack the mental capacity to contract or manage your own affairs?
NoYes

Are you aware of any good cause for the denial of the license?
NoYes

Are you prohibited from possessing firearms under federal law, including having been convicted In any court of a misdemeanor crime o fdomestic violence or being under indictment for a crime punishable by imprisonment for a term exceeding one year?
NoYes

If the answer to any of the questions above is YES, explain here:

Explanation

Explanation

Explanation

Have you been honorably discharged from the United States Army, Navy, Marine Corps, Alr Force or Coast Guard, or the National Guard of the State of New York?
NoYes

FOIL:

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 licensecurrently licensed to possess a firearm in NYS

Full Name

Address

Date of Birth

City

State

Zipcode

Firearms License # (if applicable)

Firearms License Date Issued (if applicable)

Licensing Authority/County of Issuance of Application

I hereby request that any information concerning my firearms license application or firearms license not bea public record.The grounds for which I believe my information should NOT be publicly
disclosed are as follows: (check all that are applicable)

My life or safety may be endangered by disclosure because

Disclosure:
I am an active or retired police officer, peace officer, probation officer, parole officer, or corrections officerI am a protected person under a currently valid order of protectionI am or was a witness in a criminal proceeding involving a criminal chargeI am participating or previously participated as a juror in a criminal proceeding, or am or was a member of a grand jury

My life or safety of that of my spouse, domestic partner or household member may be endangered by disclosure for some other reason explained below:(Must be explained below)

I am a spouse,domestic partner or household member of a person identified in A,B,C or D of question
(Please check any that apply)
ABCD

I have reason to believe that I may be subject to unwarranted harassment upon disclosure

(Please provide any additional supportive information as necessary:

Additional Info

Additional Info

Additional Info

I accept all my answers are truthful.