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PPB-2 (01/17) License Number State of New York Pistol / Revolver License Recertification Form County of Issue Date of Issue Have you ever transferred your pistol/revolver license from one county to another? Yes No If Yes, provide Original County of Issue: Last Name Suffix First Name MI Date of Birth – MM DD YYYY NY Driver’s License (or NY Non-Driver ID) No. Gender Social Security (Last 4 Digits) Race Height Weight Eyes Hair X X X X X ft in Since being issued a pistol/revolver license, have you ever been known by any name other than that currently appearing on your license? Yes No If Yes, furnish the following information: Other Last Name Other First Name MI Physical Address (street, city, state, zip) Mailing Address (if different) Primary Contact Telephone Number ( ) Email Address (optional) LICENSE TYPE: Carry Concealed (includes restricted or unrestricted) *Possess on Premises *Possess/Carry During Employment Premise Address or Employer/Employer Address must be provided below: Employer Name (if Carry During Employment) Street, City, Zip Code FIREARM DATA: Do you have any pistols and/or revolvers? Yes No If Yes, furnish the following information related to pistol(s) or revolver(s) in your possession: (See reverse if additional space is needed) Co-Registered Manufacturer Pistol/Revolver/ Single Shot Model Frame Only Caliber(s) Serial Number NYS FIREARMS LICENSE RECERTIFICATION - REQUEST FOR PUBLIC RECORDS EXEMPTION Are you requesting to have information concerning your firearms license recertification exempt from public record? Yes No If Yes, identify the grounds for which you believe your information should NOT be publicly disclosed by selecting all applicable statements below: 1. My life or safety may be endangered by disclosure because: [ ] A. I am an active or retired police officer, peace officer, probation officer, parole officer, or corrections officer; [ ] B. I am a protected person under a currently valid order of protection; [ ] C. I am or was a witness in a criminal proceeding involving a criminal charge; [ ] D. I am participating or previously participated as a juror in a criminal proceeding, or am or was a member of a grand jury; 2. [ ] My life or safety or that of my spouse, domestic partner or household member may be endangered by disclosure for some other reason explained below: (Must be explained in item 5 below) 3. [ ] I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1. (Please check any that apply) A 4. [ ] I have reason to believe that I may be subject to unwarranted harassment upon disclosure. 5. (Please provide any additional supportive information as necessary) I certify that the information provided on both sides of this form is correct. I also hereby affirm that, to the best of my knowledge, I am not prohibited from possessing firearms under state or federal law. I understand that false statements made herein are punishable as a Class A misdemeanor. I further understand that upon discovery that I provided any false information, I may be subject to criminal penalties, my pistol / revolver license may be revoked, and any request for public records exemption shall become null and void. Signature Date Mail to: New York State Police, Pistol Permit Bureau, Building 22, 1220 Washington Avenue, Albany, New York 12226-2252 ---PAGE BREAK--- Last Name First Name NY Driver’s License (or NY Non-Driver ID) No. FIREARMS DATA CONTINUED (Attach Form PPB-2A, if additional space is needed) Co-Registered Manufacturer Pistol/Revolver/ Single Shot Model Frame Only Caliber(s) Serial Number Mail completed forms to: New York State Police, Pistol Permit Bureau, Building 22, 1220 Washington Avenue, Albany, New York 12226-2252 Your recertification status can be checked at Your status will be “No recertification on file” until your information has been entered. Please allow sufficient time for mailing and entry.