PISTOL PERMIT DEPARTMENT - COUNTY OF OSWEGO, NEW YORK

AFFIDAVIT OF CHARACTER REFERENCE IN CONNECTION WITH THEIINVESTIGATION OF

(APPLICANT'S) LAST NAME

FIRST NAME

MIDDLE INITIAL

AN APPLICANT FOR PISTOL LICENSE/DEALER

PLEASE PRINT OR TYPE ANSWERS

DATE:______________________________

1. What is your full name? _________________________________________________________________________________

2. What is your present address?___________________________________________________________________
___________________________________YOUR HOME PHONE #___________________________________

_
3. List any other names you have ever used or have been known by (if married, give maiden name)_________________
4.
5.
6.
7

Your employer_______________________________________________________________________________________
Your business address_______________________________________________________________________________________
Your business phone #_______________________________________________________________________
Were you ever arrested, indicted, or convicted for any crime, in any jurisdiction, Federal, State or Local?
__________________________
8. Have you ever had any license or pistol permit suspended, denied or revoked by any agency, Federal, State or
Local?______________. If so, give details on reverse side of this form.
9. Do you have a pistol permit?_________If yes, date issued___________County of issuance____________________
License # ______________
10. Are you a full or part-time member of any law enforcement agency?___________________If yes, give name of
Agency__________________________________________________________________________________
11. State your relationship to the applicant (i.e friend, employer, fellow employee, etc.) NO RELATIVES ARE
ALLOWED__________________________________________________________________________________
12. How long have you known the applicant? _____________________________________________________________
13. Do you know the applicant by any other name or names?_____________________________________________
If so, please list them____________________________________________________________________________
14. Where does the applicant reside? ____________________________________________________________________
15. Where is the applicant employed? _______________________________________________________________________
16. Where was (s) he previously employed? ____________________________________________________________________
17. Was the applicant ever in your employ?____________________________For how long? ____________________________
18. Under what circumstances were the applicant's services terminated? ______________________________________________

I KNOW THE APPLICANT TO BE OF GOOD CHARACTER. I KNOW THAT BY SIGNING AS A

CHARACTER REFERENCE, I AM RECOMMENDING THE APPLICANT TO BE ISSUED A PISTOL
PERMIT TO ENABLE HIM TO OWN AND CARRY A PISTOL (HAND GUN) FOR THE PURPOSES
LISTED IN THE APPLICATION, OR IF REFERENCE FOR DEALER TO ENABLE HIM TO BUY AND
SELL HANDGUNS.
Sworn to before me this

_______day of_ _________, 20_____

SIGNATURE OF CHARACTER REFERENCE

NOTARY PUBLIC/COMM.DEEDS

PRINT NAME - CHARACTER REFERENCE

WHEN FORM HAS BEEN COMPLETED. PLEASE RETURN TO THE APPLICANT.

(REV. 10/04)