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Registration Form
 
NAME:
D.O.B.
Male Female
ADDRESS:
CITY:
STATE:
ZIP:
TEL. #
BUS. #
FAX #
Occupation:
E-MAIL:

HAVE YOU EVER BEEN CONVICTED OF A FELONY VIOLATION? YES NO
DO YOU CURRENTLY SUFFER FROM ANY FORM OF MENTAL ILLNESS? YES NO
HAVE YOU EVER BEEN COMMITTED TO A STATE MENTAL INSTITUTION? YES NO
HAVE YOU EVER BEEN CONVICTED OF DOMESTIC VIOLENCE? YES NO

COURSE ATTENDING:
COURSE DATE: - -
ALTERNATE DATE: - -
FIREARM YOU ARE USING FOR THIS COURSE:
CALIBER:
CHECK HERE IF YOU ARE REQUESTING THE USE OF A COMPANY GUN:
WHAT IS THE LOCATION OF THIS COURSE:
ARE THERE ANY HEALTH CONSIDERATIONS THAT THE INSTRUCTOR (S) SHOULD BE MADE AWARE OF? YES NO
IF YES, PLEASE EXPLAIN:

LEGAL Arizona Gun Owners Guide ($20) YES NO
   
CCW ONLY
Include 5 year AZ DPS Permit Fee ($65)		 YES NO

All courses must be paid in full prior to the first day of training in order to hold the student’s space. No one will be permitted to reserve a course space without full payment. Please include your course fee with this registration form. The course fee is NOT REFUNDABLE. I state by signing this application, that I have no violent criminal convictions, I am not under indictment or prosecution for any criminal offense and am not being sought by any L.E. Agency. I also state that I have no current mental illness or substance abuse. Returned checks have a $25 fee added to the student’s balance.

If paying by mail or fax, you will be contacted via phone or email to complete the order.
A web administration fee will be added to all Paypal orders.

Phoenix Rod & Gun Club Members receive a $10.00 rebate in class with proof of current membership!

 
Submit payment with PayPal (Secure Payment Option)
I am Faxing Credit Card Payment to 480.675.7602
I am Mailing Payment by Check or Credit Card to: 1334 E. Chandler Blvd. #5, D-69 Phoenix, AZ 85048