Parabellum Dutchess Pistol Questionnaire

Applicant Personal Information
Date of Birth*

MonthDayYear
Date
Place of Birth*
City / State -or- Country if outside of United States
Date

MonthDayYear
Date
Gender*

FemaleMaleNon-Binary
Sex
Weight*
Eye Color*
Hair Color*
Height - Feet*
Height - Inches*
What is your Drivers License Number?*
Please Upload Photo of Drivers License*

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If No Driver's License - Use Non-Driver ID # Cancelof
Social Security Number*
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Applicant Employment Information

If Unemployed or Retired, List previous Employer If Student, List School Please note - Employers will not be contacted unless also listed as references.
What is your current Employment Status?*

Employed / Self-EmployedRetiredUnemployed
Current Employer*
Occupation*
Nature of Business*
Employment Start Date*
Employment End Date*
Enter - "Current" if still employed
Current Business Address

Street Address

Apartment

CityState / Province

Postal / Zip Code
Name of Supervisor
Current Employer Phone Number

Area CodePhone Number
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Active / Retired Military
Are you Active or Retired Military?*

YesNoForeign Military
Branch of Service / Foreign Military*
What is your designated Separation Status

HonorableDishonorableGeneralMedical
If you received anything other than Honorable Discharge, please explain below
Date Separated *

MonthDayYear
Date
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Please provide information for two family members that do not live with you.
Name of Family Member that does not live with you #1*
Date of Birth Family Member #1*

MonthDayYear
Date
Phone Number Family Member #1*
Name of Family Member that does not live with you #2*
Date of Birth Family Member #2*

MonthDayYear
Date
Phone Number Family Member #2*
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Firearms Storage / Safeguard
How and where will firearm(s) be secured when not in use?*
example: They will be stored unloaded and locked inside a hidden safe.
Dutchess County requires you to choose someone to safeguard your firearms in the event of your death or serious injury. Would you like Parabellum Firearms to act as your safeguard? If not, you will enter the information for the person that you choose.

YesNo
Parabellum Name
Parabellum FFL Dealer
Parabellum Phone
Parabellum Email
Name of person who will Safeguard your firearms in the event of your death or serious injury?
Date of Birth of person who will Safeguard your firearms in the event of your death or serious injury?
Phone number of person who will Safeguard your firearms in the event of your death or serious injury?
Email address of person who will Safeguard your firearms in the event of your death or serious injury?
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Arrests / Convictions
Have you ever been arrested, summoned, charged or indicted anywhere for any offense, including sealed arrests DWI (except traffic infractions)?*

YesNo
Have you ever Failed to appear in Court?

YesNo

Do you have any additional Charges or Dispositions*

YesNo
Please write ALL details of Any Incidents listed above. NOTE - ALL INFORMATION WILL BE KEPT PRIVATE. It will help Parabellum better assist your application.*
Example - Write in your own word what happened and what you got charged with. Also include Court details.
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Personal References

Please avoid using law enforcement officers as character references, unless they are now retired.
All character references MUST be residents of Dutchess County and can not be related to you by blood or marriage.
Reference 1 Name*

First NameMiddle InitialLast Name

Reference 1 Address / Phone*

	Street Address, Apt #, City, State , Zip Code	Telephone #
Ref 1

Reference 2 Name*

First NameMiddle InitialLast Name

Reference 2 Address / Phone*

	Street Address, Apt #, City, State , Zip Code	Telephone #
Ref 1

Reference 3 Name*

First NameMiddle InitialLast Name

Reference 3 Address / Phone*

	Street Address, Apt #, City, State , Zip Code	Telephone #
Ref 1

Reference 4 Name*

First NameMiddle InitialLast Name

Reference 4 Address / Phone*

	Street Address, Apt #, City, State , Zip Code	Telephone #
Ref 1

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Handgun Information

If Licensing Officer authorizes the possession of a pistol, revolver or single shot firearm(s) at the time of issue of original license, furnish the following information. * ** List handguns only, do not list semi-automatic rifles.

Other Friends / Known Associates

Do not include people that you have listed as Character Reference
Provide name of a friend or associate #1*
NOT ONE OF YOUR CHARACTER REFERENCES
Birthdate of friend #1*

MonthDayYear
Date
Phone Number of friend #1*
Provide name of a friend or associate #2*
NOT ONE OF YOUR CHARACTER REFERENCES
Birthdate of friend #2*

MonthDayYear
Date
Phone Number of friend #2*
Provide name of a friend or associate #3*
NOT ONE OF YOUR CHARACTER REFERENCES
Birthdate of friend #3*

MonthDayYear
Date
Phone Number of friend #3*
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Please enter any handguns that you own or will co-own: Type = Pistol - Revolver - Single Shot Property Of = Name of FFL Dealer or Individual currently in possession of handgun

	Manufacturer	Type	Model	Caliber	Serial #	Property Of
1
2
3
4

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State Required Documents

NY State requires the following documents. You have the option to upload them now. We will review them to make sure they comply with the requirements. We will then print them and include them with your application package. If you prefer not to upload them now, you can add them to the application package prior to submitting it to the County.
Please upload a copy of your proof of training showing that you have taken the required 16-hour firearm safety and use course.

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Please upload a copy of your Birth Certificate or U.S. Passport

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Do you have a Utility Bill (Gas, Electric, Water, Cable, etc.) in your name?

YesNo
Please upload a copy of a Utility bill, Cable / Internet bill, Bank Statement with your name address on it. NOTE - 2 of those are required

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If you don't have utility bills in your name at your residence, please download this Proof of Residency form:

Proof of Residency Form

After you fill it out, you will upload it in the next step.
Please upload your Proof of Residency Form

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Should be Empty:

	Date	Police Agency	Charge	Disposition Date	Disposition Court	Disposition
Arrest 1
Arrest 2
Arrest 3
Arrest 4

Dutchess County Pistol Permit Application

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Applicant Personal Information

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Applicant Citizenship Information

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Applicant Employment Information

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Active / Retired Military

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Background Questions

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Household Information

Adults Residing in Home, Including Adult Children

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Please provide information for two family members that do not live with you.

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Firearms Storage / Safeguard

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Arrests / Convictions

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Background Questions

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Personal References

All character references MUST be residents of Dutchess County and can not be related to you by blood or marriage.

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Handgun Information

Other Friends / Known Associates

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State Required Documents