Suffolk Pistol Permit Application Details

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QuestionAnswer
Form NamePdcs 4406M Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namessuffolk pistol permit, suffolk pistol permit application, suffolk county pistol permit application form, suffolk county pistol permit

Form Preview Example

POLICE DEPARTMENT COUNTY OF SUFFOLK

ACCREDITED LAW ENFORCEMENT AGENCY

PISTOL LICENSE APPLICANT QUESTIONNAIRE

PDCS 4406m

PAGE 1 of 2

1.

Last Name:

7.

Date of Birth

Male

Female

 

 

 

 

 

 

2.

First Name:

8.

City of Birth

 

 

 

 

 

 

 

 

3.

Middle Name:

9.

State of Birth

 

 

 

 

 

 

 

 

4.

Suffix:

10.

Citizenship (Country):

 

 

 

 

 

 

 

 

5.

Social Security #:

11.

Marital Status:

 

 

 

 

 

 

6.

Alien Registration # (If Applicable):

12.

Type of License You Are Applying For: (See Instructions Page 1)

 

 

 

 

 

 

PHYSICAL DESCRIPTIVE DATA:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

HEIGHT (FEET/INCHES)

 

 

 

 

14.

WEIGHT (POUNDS)

 

15. RACE

 

 

 

16.

HAIR COLOR

 

 

 

 

 

 

17.

EYE COLOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

POLICE AGENCY

 

CHARGE

 

DISPOSITION

COURT & DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. List all handguns in your possession (if none, so indicate)

MANUFACTURER

PISTOL

CALIBER

SERIAL #

MODEL

PROPERTY OF

 

OR REV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.Current Employer

21.Employer Address

22.Occupation

23. Nature of Employment

24. Business Phone

 

 

 

 

25.List all prior places of employment (include business name, address, nature of business and phone #)

26.PRESENT ADDRESS: include House #, City, Village, Town, State (if other than New York), Zip Code, and Telephone # (include mailing address if different)

Address_____________________________________________

City________________________ State: New York

Zip Code______________

Home Telephone #_________________________________

Alternate/ Cell Telephone#___________________________________

Mailing Address_____________________________________________________________________________________________________________

POLICE DEPARTMENT COUNTY OF SUFFOLK

PISTOL LICENSE APPLICANT QUESTIONNAIRE (CONTINUED)

27. List all prior places of residence (include street address, city, state, and zip code)

PAGE 2 OF 2

27.LIST ALL PRIOR PLACES OF RESIDENCE (INCLUDE STREET ADDRESS, CITY, STATE, AND ZIP CODE)

28. Spouse/ Domestic Partner Name:

D.O.B.:

Telephone #: Cell Phone #:

29. If Female, Your Maiden Name and all Previous Married Names:

30. If Married, Your Spouse’s Maiden Name:

31. Mother’s Maiden Name (Last, First):

32.Father’s Name (Last, First):

33.Nicknames or Aliases (Applicant):

34.Next of Kin (include person’s Name, Address, Phone# and relation to applicant):

35.Name and address of person who will safeguard pistol (s) and notify the Pistol Licensing Bureau in case of Applicant’s death or disability. (should be a Suffolk County resident, but does not need to possess a pistol license)

Name:

Telephone:

Address:

 

36.Give four (4) character references who, by their signature, attest to your good moral character – list references alphabetically and print clearly. Each reference must personally sign form. (see qualifications in instructions)

LAST, FIRST, MI

D.O.B.

STREET ADDRESS

CITY, TOWN

TELEPHONE

SIGNATURE

37.

A license is required for the following reason: (see instructions, page 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38.

Have you ever been terminated/discharged from any employment or the armed forces for cause?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

39.

Have you ever undergone treatment for alcoholism or drug use?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40.

Have you ever suffered any mental illness, or been confined to any hospital, public or private institution, for mental illness?

YES

NO

 

 

 

 

 

 

 

 

 

41.

Have you ever had a pistol license, dealer’s license, gunsmith license, or any application for such a license disapproved , or had

 

 

 

 

 

 

such license revoked or cancelled?

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42.

Do you have any physical condition which could interfere with the safe and proper use of a handgun?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43.

Have you ever been charged, petitioned against, a respondent or otherwise been a subject of a proceeding in Family Court?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

44.

Has anyone in your household been arrested for a felony or serious offense?

YES

NO

 

 

 

 

 

 

 

 

45.

Have you or any member of your household ever been evaluated or treated as a result of any mental health issues including,

 

 

 

 

 

 

but not limited to depression?

 

YES

NO

 

 

 

 

 

 

 

 

Have you or any member of your household ever been admitted to any mental institution or hospital, public or private?

YES

NO

 

 

 

 

 

 

 

 

 

46.

Do you now or have you ever tried, used, possessed or sold marijuana or its derivatives, narcotics, controlled substances,

YES

 

NO

 

 

 

tranquilizers, or anti-depressant medication?

 

 

 

 

 

 

 

If any of these substances were prescribed by a doctor, provide doctor’s name, address, and phone number.

 

 

 

 

 

 

 

 

 

 

 

47.

Have you ever been denied appointment to a civil service position; federal, state, or local?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

48.

Have you ever served in the military? YES NO

If yes, have you ever been the subject of military discipline?

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

49.

Have you ever had any license, including, but not limited to, a driver’s license, pistol license, or liquor license issued by

YES

NO

 

 

any agency denied, revoked, cancelled or suspended?

 

 

 

 

 

 

 

 

 

 

 

 

 

50.

Have you received a traffic summons, or been arrested or convicted for any traffic infraction in the last five (5) years?

 

 

 

 

 

 

If yes, list the date(s), charge(s), police agency, court, and disposition.

YES

NO

 

 

 

 

 

 

 

 

 

51.If you have answered ‘yes’ to any of the above (questions 38 through 50) and require additional space, submit a separate detailed, notarized explanation on 8½” x 11” sized paper.

STATE OF NEW YORK

COUNTY OF SUFFOLK I ________________________________________________________________ being duly sworn, depose and say that I am the above

named person and I have signed the foregoing statement.

I have personally read and answered all questions therein and I do solemnly swear that every answer is full, true, and correct in every respect.

Sworn to before me this _________________________ Day of _________________________, _____________

_________________________________________________________

_________________________________________________________

NOTARY STAMP

SIGNATURE OF APPLICANT

SIGNATURE OF NOTARY/WITNESS

 

POLICE DEPARTMENT COUNTY OF SUFFOLK

 

CONTINUATION PAGE - IF ADDITIONAL SPACE IS REQUIRED

PDCS-4406m

STATE OF NEW YORK

COUNTY OF SUFFOLK I ________________________________________________________________ being duly sworn, depose and say that I am the above

named person and I have signed the foregoing statement.

I have personally read and answered all questions therein and I do solemnly swear that every answer is full, true, and correct in every respect.

Sworn to before me this _________________________ Day of _________________________, _____________

_________________________________________________________

_________________________________________________________

NOTARY STAMP

SIGNATURE OF APPLICANT

SIGNATURE OF NOTARY/WITNESS

 

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