N.Y. Comp. Codes R. & Regs. tit. 9 § 474.5
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
N.Y. Comp. Codes R. & Regs. Tit. 9 § 474.5