Sec. 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