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