Form Pd 641 040 – Fill Out and Use This PDF

	APPLICATION —	LICENSE DIVISION
		RIFLE / SHOTGUN SECTION
	RIFLE / SHOTGUN PERMIT
	PD 641-040 (Rev. 03-13)	120-55 Queens Blvd, B-11
		Kew Gardens, New York 11424
		718-520-9300

1.Complete each form as directed and answer all questions. All entries must be clearly printed in ink (Blue or Black) or typed.

2.The minimum age to receive a permit is 21.

3.If you were ever arrested for any crime or violation you must submit a certificate of disposition from the court concerned indicating the offense and the final disposition of the charges. You must do this even if the case was dismissed, the record sealed or the case nullified by operation of law (i.e. Youthful Offender status). The New York State Division of Criminal Justice Services will report to us every instance involving the arrest of an applicant. Do not rely on anyone’s representation that you need not list a previous arrest. ANY OMISSION OF A PREVIOUS ARREST MAY RESULT IN THE DENIAL OF YOUR APPLICATION. You must submit a notarized statement explaining the circumstances of the arrest.

4.If you were ever convicted of a felony, before your application can be considered, you must apply for a Certificate of Relief from Forfeitures and Disabilities from New York State.

5.If you were ever convicted of a Serious Offense you must get a New York State Certificate of Relief from Forfeitures and Disabilities. Serious Offenses are listed in Section 265.00(17) of the Penal Law. They include any offense involving drugs or narcotics, any sex offense, any violation of the laws pertaining to the illegal use or possession of a pistol or other dangerous weapon, possession of burglars tools and receiving stolen property.

To apply for a New York State Certificate of Relief contact either the Division of Probation, the Department of Parole or the Court in which you were convicted.

6.If you served in the Armed Forces of the United States, you must submit your separation papers (DD 214) and your discharge. If you were issued other than an honorable discharge, you must submit a notarized statement explaining the reason for discharge.

7.If your answer to any of Questions 3, 4 or 5 on the application is YES you must submit a letter from a licensed physician stating that he/she has examined you within the last 30 days, that the examination included a review of your past medical history and all pertinent hospital and institutional records, and must conclude that you are capable of possessing a rifle and or shotgun without presenting a danger of harm to yourself (applicant) or to others. Further evidence may be requested.

8.Two separate fees are required. These are payable by certified check, bank check, money order or credit card. All fees are non-refundable.

–$140.00 Made payable to New York City Police Department.

–$91.50 Made payable to New York City Police Department. (for fingerprints)

9.You will be fingerprinted at the Rifle/Shotgun Section.

10.Four color photographs, (Taken from the chest up, 1½ x 1½), of the applicant must accompany the application. (Taken within last 30 days)

11.You must submit proof of your present address. Proof must consist of a utility bill ( gas, electric or phone) showing your name and current address and not more than sixty (60) days old, or a notarized lease. If you do not have a lease or a utility bill in your name, a notarized statement from the person with whom you reside, accompanied by a utility bill in their name showing the same address is acceptable. Further documentation may be required.

12.If you were born in the United States, you must submit your birth certificate. If there is no record of your birth on file with the Department of Health or the Bureau of Vital Statistics, some other proof of your birth date, e.g., a military record, or U.S. Passport must be submitted.

13.If you were born outside of the United States, you must submit your naturalization papers, valid U.S. Passport or other evidence of citizenship if derived from your parents. All other applicants born outside the United States must submit their ALIEN

REGISTRATION CARD.

14.Submit signed and notarized (where required) statements regarding arrest history, affidavit of familiarity, affidavit of co-habitant and acknowledgment of person agreeing to safeguard firearms along with the application.

15.It is unlawful to possess firearms in New York City without a possession permit issued by the Police Department.

All rifles and shotguns owned by a permit holder must be registered with the Police Department. There is no charge for registering firearms. The registration of a rifle or shotgun can be accomplished by filling out the registration form PD 641-121 and mailing the two top copies (Green) to: License Division, Rifle/Shotgun Section, Room B11, 120-55 Queens Blvd., Kew Gardens, N.Y. 11424.

16 You must bring your original Social Security card with you when you apply.

INFORMATION REQUEST

LICENSE DIVISION

WAIVER OF CONFIDENTIALITY

RIFLE/SHOTGUN SECTION

PD 641-030 (Rev. 04-06)

120-55 Queens Blvd. Room B11

Kew Gardens, New York 11424

Last Name

First Name

Middle

Social Security No.

Address (Number and Street)

Apt./Floor

City

State

Zip Code

Home Phone

Business (Day Time) Phone

Employer

Occupation

Employer Address/Place of Business

Date of Birth

Place of Birth

Height

Weight

Color of Hair

Color of Eyes

I __________________________________________ residing at ________________________________________

__________________________________ do hereby consent to the release by the State Department of Mental Hygiene,

and any of its institutions, employees or agents, of any record regarding my institutionalization or treatment for any psychiatric or mental disease or disability. These records will be for the sole purpose of evaluating my application for a New

York City Rifle/Shotgun Permit.
_______________	________________________________
Date	Applicant’s Signature

To: The New York State Department of Mental Hygiene

The person described above has applied to the New York City Police Department for a permit to possess a rifle and/or shotgun. In order to determine whether the permit should be issued, additional information about the applicant is needed. It is therefore requested, pursuant to law, that any record concerning the applicants institutionalization or treatment for mental disease be furnished to us.

Rifle/Shotgun Section - License Division

New York City Police Department

For Use By State Department of Mental Hygiene

RULES AND REGULATIONS

FOR

RIFLE AND SHOTGUN PERMIT HOLDERS

All New York City Rifle and Shotgun permit holders must be aware of the responsibilities incurred by accepting a permit. They should especially be familiar with the regulations applicable to the possession of a rifle or shotgun or both. The Police Commissioner has developed the following rules and regulations for the proper and safe use of rifles and shotguns. A violation of these provisions may result in suspension or revocation of your rifle or shotgun permit.

(1)The permit issued to you by the Rifle and Shotgun Section enables you to POSSESS only RIFLES OR SHOTGUNS that are properly registered under your permit. In order to be able to possess any other type of firearm you must apply for a handgun license with the LICENSE DIVISION of the New York City Police Department.

(2)Your rifle or shotgun can not be loaded in public within New York City at any time except when using it at a licensed rifle and shotgun range.

(3)If you transport or use your rifle or shotgun, your permit must be on your person at all times. In addition, you must have in your possession the certificate of registration for each firearm you are carrying or using. Upon request of a police officer, you are required to produce your permit and certificate of registration. If you fail to produce these documents, it will then be presumed that you do not legally possess the firearm, and you may be subject to arrest and criminal penalties.

(4)When you travel to and from an authorized range or hunting area, or transport your firearm for any reason, the firearm must be carried unloaded in a non-transparent case, and the ammunition must be carried separately. If you are transporting your firearm in a vehicle, it should be kept locked in the trunk. NEVER leave your firearm in an unattended vehicle.

(5)You may never alter, remove, obliterate or deface any of the following markings that appear on your firearm: (1) name of the manufacturer; (2) model or (3) serial number. This information identifies the rifle or shotgun as legally in your possession.

(6)You may sell or dispose of your firearm only to a licensed dealer in rifles and shotguns; to the holder of a valid rifle and shotgun permit; to an individual who is exempt from permit requirements by law (e.g., Police Officers); or to a non- NYC resident who is not subject to the permit requirements of New York City. When you sell your rifle or shotgun, you must complete a certificate of registration. This form may be obtained from the Rifle and Shotgun Section or the licensed dealer when purchasing your firearm.

(7)You must take proper safety measures at all times to safeguard your firearm from unauthorized persons-especially children. Your rifle or shotgun should be kept unloaded in a secure location in you home. Ammunition should be stored separately from you rifle or shotgun. (NOTE: Many firearms that are stolen during residential burglaries are taken from bedroom closets.)

It shall be unlawful for any person or business enterprise to dispose of any weapon which does not contain a safety-locking device.

A safety locking device shall mean a design adaptation or attachable accessory that will prevent the use of the weapon by an unauthorized user, and includes, but is not limited to, a trigger lock, which prevents the pulling of the trigger without the use of a key, or a combination handle, which prevents the use of the weapon without the alignment of the combination tumblers.

While there is no limit in the number of rifles or shotguns you may possess, you should be aware that permit holders who own several firearms are expected to properly safeguard and maintain each rifle or shotgun.

(8)Minors under the age of eighteen may carry or use your rifle or shotgun only in your actual presence. As a permit holder, you will be held responsible to closely supervise any minor using your firearm. The minor, in turn, will be expected to abide by the same rules and regulations as the permit holder.

(9)It is recommended that new permit holders take advantage of instruction and safety courses in the use of firearms that are offered by rifle ranges and clubs within the New York area. Consult the local consumer telephone directory to find out more about courses offered in your area.

(10)The NYS Legislature, the City Council or the Police Commissioner may enact new laws or amendments of existing rules and regulations affecting the ownership or use of firearms. As a permit holder, you will be held responsible to know of any modification of the laws or rules governing your permit

(11)If your permit has been lost or stolen, contact your local precinct and the Rifle/Shotgun Section. If you have any questions concerning your permit or the use of your firearm, contact the Rifle and Shotgun Section, 120-55 Queens Boulevard, Room B11, Kew Gardens, NY 11424. Telephone number (718) 520-9300.

REMINDER: Your permit to possess a rifle or shotgun is valid for three years from the date it was issued. It is your responsibility to renew your permit on or before the day it expires. Failure to renew your permit will result in confiscation of your permit and any firearms you may possess.

Sources: NYC Administrative Code Sections 10-131 et seq. and Title 38 of the Rules of the City of New York.