Form Ppb-2 - Pistol/revolver License Recertification Form
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2PPB-2 (01/17)
License
County
State of New York
Number
of Issue
Pistol / Revolver License
Date of
Recertification Form
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
ft
in
X
X X
X
X
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)
Pistol/Revolver/
Frame
Co-Registered
Manufacturer
Model
Caliber(s)
Serial Number
Single Shot
Only
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 _____ B_____ C_____ D_____
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
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