NYSFTA
Date:
First Name:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Agency Name:
Circle one: ActiveRetired
Do you carry a firearm for your agency? YesNo
Do you have arrest powers? YesNo
Are you subject of any disciplinary action by the agency which could result in suspension or loss of police powers? YesNo
How many years have you been a Peace/Police Officer?
If Retired - Pistol License #:
County:
Sign: