INSTRUCTIONS: Print or type in black ink only
NYSID Number
PPB 3 (Rev. 06/17)
County of Issue
License Number
STATE OF NEW YORK
PISTOL /REVOLVER LICENSE APPLICATION
Code
Date of Issue
Month Da
Yea
Expiration Date
Month Da
Yea
In accordance with the Federal Privacy Act of 1974, you are hereby notified that your Social Security Number is not mandated by law. It is required by the
Pistol Permit Bureau as part of the standard for recording Firearms. Failure to disclose your Social Security Number will prohibit your transaction from being
recorded. The State Police will release your Social Security Number only for reasons required by law or with your written consent.
Last Name Suffi
First Name MI Date of Birth
MM DD YYYY NY Driver’s License
or NY Non-Driver ID
No.
Gende
Social Securit
Race Hei
ht Wei
h
E
es Hai
Citizen of U.S.A
ft in
YES NO
Physical Address (Street number, street name, apartment number, city, state, zip code)
Mailing Address (If different from physical address)
Primary Phone Number Secondary Phone Number Email Address
Employed By Present Occupation Nature of Business
Business Address (Street number, street name, apartment number, city, state, zip code)
I hereby apply for a Pistol / Revolver License to: (Check only one) Carry Concealed * Possess on Premises * Possess / Carry During Employment
( * ) Premise Address or Employer Name and Address must be provided below:
Employer Name (If Carry During Employment) Address or Other Location (Street number, street name, apartment number, city, state, zip code)
A license is required for the following reasons:
Give four character references who by their signature attest to your good moral character.
Last, First, MI Street Address, (Street number, street name, apartment number, city, state, zip code) Signature
Have you ever been arrested, summoned, charged or indicted anywhere for any offense, including DWI (except traffic infractions)? YES NO
If Yes, furnish the following information:
Arrest Date Police Agency Charge Disposition Date Disposition Court Disposition
Are you a fugitive from justice?
YES NO
Are you an unlawful user of or addicted to any controlled substance as defined in section 21 U.S.C. 802?
YES NO
Are you an alien illegally or unlawfully in the United States?
YES NO
Are you an alien admitted to the United States who does not qualify for the exceptions under 18 U.S.C. 922 (y)(2)?
YES NO
Have you been discharged from the Armed Forces under dishonorable conditions?
YES NO
Have you ever renounced your United States citizenship?
YES NO
Have you ever suffered any mental illness?
YES NO
Have you ever been involuntarily committed to a mental health facility?
YES NO
Have you ever had a pistol / revolver license revoked?
YES NO
Are you under any firearms suspension or ineligibility order issued pursuant to the provisions of section 530.14 of the
criminal procedure law or section eight hundred forty-two-a of the family court act?
YES NO
Have you 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, mental illness, incapacity, condition or disease you lack the mental capacity to contract or
manage your own affairs?
YES NO
Are you aware of any good cause for the denial of the license?
YES NO
Are you prohibited from possessing firearms under federal law, including having been convicted in any court of a
misdemeanor crime of domestic violence or being under indictment for a crime punishable by imprisonment for a term
exceeding one year?
YES NO
If the answer to any of the questions above is YES, explain here:
ROCKLAND
