PPB-5 (REV. 02/17)
STATE OF NEW YORK
PISTOL / REVOLVER LICENSE AMENDMENT
Amendment form for (check one):
______________________________________ County License
OR
New York State Police Pistol License
Nam
e
D
ate of Birth NY Driver’s License No. (or NY Non-Driver ID No.)
Physical Address (street, city, state, zip)
Mailing Address (if different)
TRANSACTION TYPE(S) (Check all that apply):
Acquired Address Change Deceased Disposed Duplicate Lost / Stolen Firearm Name Change
Revoked Surrendered Suspended Transfer Other
AMEND LICENSE FOR THE FOLLOWING
3. New Mailing Address (If different)
4. Following Weapon(s) Acquired From: (Name, Address)
Manufacturer
Pistol / Revolver /
Single Shot
Model
Frame
Only
Caliber(s) Serial Number
5. Following Weapon(s) Disposed to: (Name, Address)
Manufacturer
Pistol / Revolver /
Single Shot
Model
Frame
Only
Caliber(s) Serial Number
6. Following Weapons(s) has been: Lost Stolen Destroyed
Law Enforcement Agency Reported To:
Manufacturer
Pistol / Revolver /
Single Shot
Model
Frame
Only
Caliber(s) Serial Number
Have you been arrested, indicted, or convicted of any criminal offense, been the subject of an order of protection, or been
a patient at any mental institution since the above license was issued?
Yes No If Yes, give details on reverse.
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