1 New york city Police Department License Division One Police Plaza, Room 110 New york , NY 10038 Office- (646) 610-5536 Fax- (646) 610-6399 INSTRUCTIONS FOR NYPD RETIREES Please note: these instructions apply to NYPD retirees who are New york city residents only. We recommend that approximately 2 weeks prior to your anticipated retirement processing date that you hand-deliver the following materials to the License Division Retiree Section, One Police Plaza, Room 110A: A completed handgun license application form (PD 643-041). This form must be typed. There is a form-fillable .pdf file available for download on the License Division Retiree web page for this purpose. One (1) recent color passport-type photograph (1 x 1 inches), front view. A non-refundable fingerprint fee of $ which may be paid by credit card or money order (Postal or Bank). Money orders should be made payable to the New york city Police Department .
2 This fee must be paid by all applicants. The completed Firearm Removal Inquiry form, the Affidavit of Familiarity with Rules and Laws form, the Acknowledgement of Person Agreeing to Safeguard Firearms form and the Affidavit of Co- habitant form. On Your Retirement Processing Date: First, report to the Police Pension Fund, 233 Broadway, 19th floor, New york , NY. Next, report to the License Division Retiree Section, 1 Police Plaza, Room 110A, with your ID card stamped Retired. All NYC Police Department retirees must submit their Pistol License Inquiry Response form (PD 643-155) and their Property Receipt/Discontinuance of Service form (PD 520-013). You are not required to voucher your firearms if you have received a Law Enforcement Officers Safety Act Firearm Certification Card or your license will be issued on your retirement date. Follow instructions of License Division personnel regarding license issuing procedure.
3 Important Note: When you deliver your handgun license application documents, you must inform the License Division of your anticipated retirement date. A retired law enforcement handgun license will not be issued to you if your did not receive a Pistol License Inquiry Response form (PD 643-155) good-guy letter, of if your ID card is stamped No Firearms. To obtain a retired law enforcement license, you must have the restriction lifted prior to receiving a license. If you have any questions concerning your application, please call (646) 610-5536. Applications must be submitted in person at the license division, Room 110A, Monday through Friday between the hours of 0830 to 1600 hours. Rev. Sept. 2016 1 of 5 HANDGUN LICENSE APPLICATIONPOLICE Department city OF NEW YORKPD 643-041 (Rev. 11-10)LICENSE DIVISION1 Police PLAZANEW york , 10038 All applications must be typewritten.
4 DO NOT MAKE ENTRIES IN SHADED AREAS. Necessary fee mustaccompany application. Make Bank Check, Certified Check or Money Order payable to the PoliceDepartment, city of New york . Payment may also be made by credit card. Not refundable if applicationis disapproved. (Administrative Code Sec. 10-131)SECTION ATO BE ANSWERED BY ALL APPLICANTS CARRY BUSINESS CARRY GUARD/SECURITY RETIRED Police OFFICER LIMITED CARRY GUN CUSTODIAN PREMISES (Indicate Residence Business) SPECIAL (out of city validation.) CARRYP hoto taken within30 days prior to dateof VIEW1 x 1 SquareYEARLICENSE NUMBER (Renewal Applicant)Do you possess any otherNYC Handgun If YESTYPELIC. USE ONLYNYSID NUMBERDATEAPPLICATION NUMBEROLD LICENSE NUMBER Complaint No. Lost MutilatedCorp CodeCust Code1. Last NameFirst Name/Alias2. Legal Address (Street No.) Apt. # city or TownStateZip Code3 CitizenAlien Registration Number Social Security NumberRes.
5 CodeTotal Guns Code AlienHome Phone No. Cell Phone No. Email Address4. Place of Birth - city , State, CountryAgeDate of BirthHgt. (inches) of HairColor of EyesEMPLOYMENT INFORMATION5. Name of BusinessType of BusinessBus. Business Address (Street No.) city or TownStateZip Code7. Bus. Telephone (Owner - Employee - Gun Custodian)How many other persons in this businesshave Handgun Licenses?8. If applicable, list name, job title and license number of company gun custodianVALIDATION OF OUT OF city LICENSE (Special Handgun License ONLY)9. Basic License NumberIssued ByCountyDate IssuedExpiration DateLIST HANDGUNS FOR THIS APPLICATION ONLY10.(ORIGINAL APPLICANT LEAVE BLANK)TYPEOWNERR RevolverE EmployerMAKEMAKEMODELGUN SERIAL NUMBERCALIBERA AutomaticSSelfCODE001002 OFFICIAL USE ONLY Right ThumbNOTICEP ursuant to Penal Law Section (5), thename and address of any person to whom anapplication for any license has been granted,shall be a public OF PERSON PRINTED2 of 5 Applicants must answer questions 10 through 24.
6 Additionally questions 29 through 31 must be answeredchronologically and in detail. If you have answered YES to question(s) 10 through 28 you MUST use theHANDGUN LICENSE APPLICATION ADDENDUM (PD 643-041A ) to explain such answer(s) in complete detail. A FALSESTATEMENT SHALL BE GROUNDS FOR DENIAL OF A HANDGUN LICENSESECTION B HAVE YOU Had or ever applied for a Handgun License issued by any Licensing Authority in .. Yes No11. Been discharged from any employment? .. Yes No12. Used narcotics or tranquilizers? List doctor s name, address, telephone number, in explanation.. Yes No13. Been subpoenaed to, or testified at, a hearing or inquiry conducted by any executive,legislative or judicial body? .. Yes No14. Been denied appointment in a civil service system, Federal, State, Local?.. Yes No15. Served in the armed forces of this or any other country?
7 Yes No16. Received a discharge other than honorable? .. Yes No17. Been rejected for military service?.. Yes No18. Are you presently engaged in any other employment, business or profession where a need for afirearm exists?.. Yes No19. Had or applied for any type of license or permit issued to you by any city , State or Federal agency? .. Yes No20. Has any corporation or partnership of which you are an officer, director, or partner, ever applied for or beenissued a license or permit issued by the Police Dept? Give type, year, license number, in Yes any officer, director or partner ever applied for or been issued a license or permit issued bythe Police Department ? Give type, year, license number, in Yes No21. Suffered from mental illness, or due to mental illness received treatment, been admitted to a hospitalor institution, or taken medication? List Doctor s/Institutions, Name, Address, Phone #, in explanation.
8 Yes No22. Have you ever suffered from any disability or condition that may affect your ability to safelypossess or use a handgun? List Doctor s Name, Address, Phone #, in Yes NoNOTE:The following conditions must be listed: Epilepsy, Diabetes, Fainting Spells, Blackouts, Temporary Loss of Memory or anyNervous answering questions number 23 thru 26, read paragraph 7 of the instructions Been arrested, indicted, or summonsed for ANY offense other than Parking Violations, in ANY jurisdiction,federal, state, local or foreign? You must include cases that were dismissed and/or the record the following: date, time, charge(s),disposition, court and Police agency.(False statements are grounds for disapproval).. Yes No24. Have you ever, or do you now have an Order of Protection issued against you? .. Yes No25. Have you ever, or do you now have an Order of Protection issued by you against a member of yourhousehold, or any family member?
9 Yes No26. Have you ever, or do you now have an Order of Protection issued by you against a person other thana member of your housold or family? .. Yes NoIf you have answered yes to questions 24 - 26, you must indicate the following information:a. Court of Issuanceb. Date of Issuancec. Complainant s Name, Address and Telephone Numberd. Complainant s relationship to youe. Reason for issuance of Order of Protection27. Have the Police ever responded to a domestic incident in which you were involved? .. Yes No28. Used any variation in spelling of your name or any other name used? (Alias), Yes No3 of 5 LIST ALL PLACES OF RESIDENCE FOR PAST FIVE (5) YEARSRESIDENCE (Include State, County, Zip Code and Apt. No.)FROMTO(MONTH AND YEAR) (MONTH AND YEAR)OCCUPATIONPRECINCTLIST ALL PLACES OF EMPLOYMENT FOR PAST FIVE (5) YEARSBUSINESS NAME AND ADDRESS (Include State, County, Zip Code and Apt.)
10 No.)30. How and where will handgun(s) be safeguarded when not in use? (Location outside of Stateis unacceptable).31. Give name, address, relation and telephone number of person who will safeguard handgun(s) in case ofapplicant s death or disability. Must be a State undersigned affirms that the statements made and answers given herein are accurate and complete, and hereby authorizesthe New york city Police Department , License Division to make appropriate inquiries in connection with processing thisapplication. False written statements in this document are punishable under Section of the New york Penal Law(making a punishable false written statement) and also will be sufficient cause for denial of an application, license or permit bythe New york city Police Department , License _____ Signature _____INVESTIGATING OFFICER S SIGNATUREDATETAX REGISTRY NO. APPROVAL DISAPPROVAL and REASONSUPERVISOR S SIGNATUREDATETAX REGISTRY NO.