Fillable PISTOL / REVOLVER LICENSE AMENDMENT OR (monroe county)

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PISTOL / REVOLVER LICENSE AMENDMENT OR (monroe county)

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PPB-5 (REV. 02/17)
STATE OF NEW YORK
PISTOL / REVOLVER LICENSE AMENDMENT
NYSID #
Date:
Amendment form for (check one):
______________________________________ County License
OR
New York State Police Pistol License
Name
Date of Birth NY Driver’s License No. (or NY Non-Driver ID No.)
Pistol License Number
Date Issued
Duplicate License Number
Date Issued
Transfer License Number
Date Issued
Transferred From
Transferred To
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
1. New Name
2. New Physical Address
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.
Licensing Officer
Signature of Licensee
Monroe
✔
Use the boxes below if additional space is needed.
Acquired, Disposed,
Lost, Stolen or
Destroyed
Manufacturer
Pistol /
Revolver /
Single Shot
Model
Frame
Only
Caliber(s) Serial Number
Name:
Carry No.:
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PISTOL REVOLVER LICENSE AMENDMENT OR (monroe county)

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Completed 14 February 2021

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