***Application to Purchase Pistol or Revolver
***Date Hour **A.M. P.M.
***Name
***Address
***(Street and number)******(City or town)******(State)
***Date of Birth Place of Birth
***Height Weight Color hair
***Color eyes
***Scars
***Tattoos
***Other identifying marks
***Are you a citizen of the United States
***Are you a citizen of Rhode Island
***How long
***Where stationed
***(Armed Forces only)
***Have you ever been convicted of a crime of violence
***(See § 11-47-2)
***Have you ever been adjudicated or under confinement as addicted to a controlled substance
***Have you ever been adjudicated or under confinement for alcoholism
***Have you ever been confined or treated for mental illness
***From whom is pistol or revolver being purchased
***Seller's address
***Seller's signature
***Applicant's signature
***(See § 11-47-23 for penalty for false information on this application)
***(Reverse side of application form)
***AFFIDAVIT: I certify that I have read and am familiar with the provisions of §§ 11-47-1 – 11-47-55, inclusive, of the general laws of the State of Rhode Island and Providence Plantations, and that I am aware of the penalties for violation of the provisions of the cited sections. I further certify that I have completed the required basic pistol/revolver safety course.
***Signed
***(over)
***County of
***State of Rhode Island
***Subscribed and sworn before me this.*.*.*. day of.*.*.*. A.D. 20.*.
***Notary Public
***Date Hour **A.M. P.M.
***Name
***Address
***(Street and number)******(City or town)******(State)
***Date of Birth Place of Birth
***Height Weight Color hair
***Color eyes
***Scars
***Tattoos
***Other identifying marks
***Are you a citizen of the United States
***Are you a citizen of Rhode Island
***How long
***Where stationed
***(Armed Forces only)
***Have you ever been convicted of a crime of violence
***(See § 11-47-2)
***Have you ever been adjudicated or under confinement as addicted to a controlled substance
***Have you ever been adjudicated or under confinement for alcoholism
***Have you ever been confined or treated for mental illness
***From whom is pistol or revolver being purchased
***Seller's address
***Seller's signature
***Applicant's signature
***(See § 11-47-23 for penalty for false information on this application)
***(Reverse side of application form)
***AFFIDAVIT: I certify that I have read and am familiar with the provisions of §§ 11-47-1 – 11-47-55, inclusive, of the general laws of the State of Rhode Island and Providence Plantations, and that I am aware of the penalties for violation of the provisions of the cited sections. I further certify that I have completed the required basic pistol/revolver safety course.
***Signed
***(over)
***County of
***State of Rhode Island
***Subscribed and sworn before me this.*.*.*. day of.*.*.*. A.D. 20.*.
***Notary Public
