LAST NAME; FIRST NAME; MI; DOB-M/D/Y; SEX
RESIDENCE ADDRESS; CITY, VILLAGE, TOWN AND STATE IF OTHER THAN NEW YORK; ZIP CODE
HGT(INS); WGT (LBS); EYES; HAIR; RACE; SOCIAL SECURITY NUMBER; PRESENT OCCUPATION; CITIZEN OF USA, YES, NO
EMPLOYED BY; NAME OF BUSINESS; BUSINESS ADDRESS

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I HEREBY APPLY FOR A PISTOL/REVOLVER LICENSE TO: (Check one only)  [] CARRY CONCEALED [] *POSSESS ON PREMISES
[] * POSSESS/CARRY DURING EMPLOYMENT (*Premise address or place of employment must be provided)

STREET ADDRESS OR OTHER LOCATION                                    CITY, VILLAGE, TOWN                                                    ZIP CODE

A LICENSE IS REQUIRED FOR THE FOLLOWING REASON:

______________________________________________________________________________________________________
GIVE FOUR CHARACTER REFERENCES WHO BY THEIR SIGNATURE ATTEST TO YOUR GOOD MORAL CHARACTER
LAST NAME                                                                STREET ADDRESS                                            CITY, VILLAGE, TOWN           SIGNATURE
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

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HAVE YOU EVER BEEN ARRESTED OR INDICTED ANYWHERE FOR ANY OFFENSE, INCLUDING DWI (EXCEPT TRAFFIC INFRACTIONS)?
[] YES  [] NO  IF YES, FURNISH THE FOLLOWING INFORMATION:

 DATE                                       POLICE AGENCY                                      CHARGE                                 DISPOSITION - COURT AND DATE
______________________________________________________________________________________________________
______________________________________________________________________________________________________

HAVE YOU EVER BEEN TERMINATED/DISCHARGED FROM ANY EMPLOYMENT OR THE ARMED FORCES FOR CAUSE?                             [] YES [] NO

HAVE YOU EVER UNDERGONE TREATMENT FOR ALCOHOLISM OR DRUG USE?                                                                                           [] YES [] NO

HAVE YOU EVER SUFFERED ANY MENTAL ILLNESS, OR BEEN CONFINED TO ANY HOSPITAL, PUBLIC OR                                                 [] YES [] NO
PRIVATE INSTITUTION, FOR MENTAL ILLNESS?

HAVE YOU EVER HAD A PISTOL LICENSE, DEALER'S LICENSE, GUNSMITH LICENSE, OR ANY APPLICATION                                               [] YES [] NO
FOR  SUCH A LICENSE DISAPPROVED, OR HAD SUCH A LICENSE REVOKED OR CANCELLED?

DO YOU HAVE ANY PHYSICAL CONDITION WHICH COULD INTERFERE WITH THE SAFE AND PROPER USE OF                                       [] YES [] NO
A HANDGUN?

HAVE YOU EVER BEEN CHARGED, PETITIONED AGAINST, A RESPONDENT, OR OTHERWISE BEEN A SUBJECT                                           [] YES [] NO
OF A PROCEEDING IN FAMILY COURT?

IF ANSWER TO ANY QUESTION IS YES, EXPLAIN HERE:

____________________________________________________________________________________________________________________________________________
                                                                    ANY OMISSION OF FACT OR ANY FALSE STATEMENT WILL BE SUFFICIENT CAUSE
                                                                    TO DENY THIS APPLICATION AND CONSTITUTES A CRIME PUNISHABLE BY FINE,
                                                                    IMPRISONMENT, OR BOTH.
             PHOTOGRAPH
             OF APPLICANT                            I AM AWARE THAT THE FOLLOWING CONDITIONS AFFECT ANY LICENSE WHICH
 TAKEN WITHIN 30 DAYS                     MAY BE ISSUED TO ME:
                                                                       1. NO LICENSE ISSUED AS A RESULT OF THIS APPLICATION IS VALID IN THE CITY OF NEW YORK
                                                                        2. ANY LICENSE ISSUED AS A RESULT OF THIS APPLICATION WILL BE VALID ONLY FOR A PISTOL OR
                                                                           REVOLVER SPECIFICALLY DESCRIBED IN THE LICENSE PROPERLY ISSUED BY THE LICENSING OFFICER.
                _________                                         3.  IF I PERMANENTLY CHANGE MY ADDRESS, NOTICE OF SUCH CHANGE AND MY NEW ADDRESS MUST
                                                                            BE FORWARDED TO THE SUPERINTENDENT OF THE STATE OF POLICE AND IN NASSAU COUNTY AND
                                                                            SUFFOLK COUNTY
                                                                            TO THE LICENSING OFFICER OF THAT COUNTY, WITHIN 10 DAYS OF SUCH CHANGE.
                                                                        4.  ANY LICENSE ISSUED AS A RESULT OF THIS APPLICATION IS SUBJECT TO REVOCATION AT ANY
                                                                            TIME BY THE LICENSING OFFICER OR ANY JUDGE OR JUSTICE OF A COURT OF RECORD.
        FULL FACE ONLY
                                                                                    __________
                                                                                          JURAT:
                                                                                          SIGNED AND SWORN TO BEFORE ME

                                                                                          THIS  _______________ DAY OF ____________________ , 19 ______

                                                                                           AT __________________________________________ , NEW YORK

_________________________________                                   __________________________________________________________
                                                                                                                                SIGNATURE OF OFFICER ADMINISTERING OAT

                                                                                          _________________________________________________________________________________
                                                                                                                                            TITLE OF OFFICER
THIS FORM APPROVED BY SUPERINTENDENT OF STATE POLICE AS
REQUIRED BY PENAL LAW SECTION 400.00, SUBD.3.                             APPLICATION NOT VALID UNLESS SWORN

    139-PPB3
    139-PPB3A