9 CRR-NY 474.5NY-CRR
9 CRR-NY 474.5
9 CRR-NY 474.5
474.5 Form—certification for the purchase of a self-defense spray device.
CERTIFICATION FOR THE PURCHASE OF A SELF-DEFENSE SPRAY DEVICE
(Pursuant to Penal Law, § 265.20(a)(15)(B))
Name of Purchaser:
Date of Purchase:
/ /
Last First M.I.
Date of Birth:
/ /
Height:
___
Weight:
___
Social Security No.
Address:
Street
City
State
Zip Code
County of Residence: ______
Purchaser's Identification:
(Driver's License Number or other identification which shows name, date of birth, place of residence)
Brand of Self-Defense Spray Devices:
Number of Containers Purchased: □
1
□
2
Container Net Weight:
Name of Vendor:
Vendor's License No.:
Address:
Street
City
State Zip Code
Vendor Type: □ Pharmacists □ Firearms Dealer
Signature of Vendor
PURCHASER'S VERIFICATION
I, ________, do hereby verify that I am over eighteen years of age, and that I have not been convicted of a felony or an assault in New York, or any other State.
I understand that false statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.
Signature of Purchaser
This form approved by the Superintendent of State Police
9 CRR-NY 474.5
Current through September 15, 2021
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