Reason: CAPS #: __________________
☐ NYS Pistol Permit Application
☐ Out of State Pistol Permit Spillman #: _______________
☐ Civilian Prints
☐ Other
Name: ________________ _________________ ____________
(Last name) (First Name) (Middle)
Height: __’____” Weight: ________lbs
Sex: (circle one): Male/Female Race: ____________________
Hair Color: _______________ Eye Color: ________________
Date of Birth: __________________
City of Birth/State (i.e. Nyack, NY): __________________________
Citizenship: ___________________ US/Other: ________________
(City, State/Country)
Social Security #: ________________ Marital Status: _____________
License Type (Class C, D, DM, etc.): _________________
Street Address: ________________________________________
(Street)
________________________________________
City, State, Zip Code
Email:________________________@____________.____
Phone (Home): _________________ Phone (Cell): ______________
APPLICANT FINGERPRINT INFORMATION
To be completed by the person fingerprinted
