DISCLOSURE FORM
ARREST/CHARGE AFFIDAVIT
To All Pistol Permit Applicants - Rockland County
Your pistol license application specifically states: "Have you ever been arrested, summoned, charged, or indicted anywhere for
any
offense including D.W.I. (Except Traffic Infractions)?" Check response: YES NO .
Yo
u MUST
provide information about any and all arrests including; tickets for Vehicle and Traffic Law arrests for driving with a
Suspended Driver License or Driving with a Suspended Registration; any youthful offender arrest; any arrests sealed in your favor;
any arrest dismissed upon your first appearance; any arrest dismissed via ACD and any arrest voided by the arresting agency or District
Attorney's Office, even if your lawyer at the time of the case advised you that you did not have to tell anyone about your arrest. You
may have been arrested even if you were never fingerprinted or photographed. You may have received a UTT (traffic ticket), a paper
summons or appearance ticket and were not taken into custody. The Sheriff will verify the information you provide.
IF YOU HAVE EVER BEEN ARRESTED, YOU MUST FURNISH A CERTIFIED COPY OF THE DISPOSITION OR
YOUR APPLICATION WILL NOT BE PROCESSED.
A FAILURE TO PROVIDE INFORMATION OF ANY KIND RELATED TO ANY INCIDENT WHEREIN YOU WERE
ARRESTED, SUMMONED, CHARGED, OR GIVEN AN APPEARANCE TICKET IS CONSIDERED AN UNTRUTHFUL
APPLICATION AND WILL RESULT IN A RECOMMENDATION OF DISAPPROVAL TO THE LICENSING
AUTHORITY.
N
OTICE: You MUST also provide all police interactions you have during your application period. You will provide this information
in writing within five (5) business days of any police interaction.
"By applying for a Pistol Permit, I understand that I am required to state whether any Mental Health, Alcoholism, and/or Substance
Abuse records exist, and authorize their release to the Sheriff and the Judge who will pass on my application to the pistol clerk".
(Note: The existence of any such record will not automatically disqualify you, but the false denial or omitting of such existence will
cause the denial of the application and may subject you to prosecution for the crime of making a false statement).
Pick one:
1. My name is___________________________________________________ and I have never been known by any other name.
2. My name is and I have also been known as:
____
_________________________________________________________________________________________________.
Phone no.: Cell:
Home:
Work: ______________________
I have read and I understand the above information and the consequences of failing to provide
information as directed
.
S
IGNED: ________________________________________________________________DATE: _____________________________
DONNA G. SILBERMAN
County Clerk
COUNTY OF ROCKLAND
OFFICE OF THE COUNTY CLERK
1 SOUTH MAIN STREET - SUITE 100
NEW CITY, NEW YORK 10956-3549
Phone # (845) 638-5070
Fax # (845) 638-5647
Email : rocklandcountyclerk.com
Website: rocklandcountyclerk.com
Deputy County Clerks
Jamie Graham
Joseph Alongi
William Phillips
