Course Name ___________________________ Course Date   ____________Current Date ______________

Name ________________________________________

Address ________________________________________

City ________________________________________ State __________ Zip Code ______________________

Email __________________________________ Primary Phone #_____________________________________

Occupation _________________________________ Employer ______________________________________

Date of Birth ___________________________ Place of Birth________________________________________

Primary Defense Firearm:  Make _____________________ Model ________________ Caliber  _____________

Prior Training: _____________________________________________________________________________

Emergency Contact Name_______________________Emergency Contact #____________________________

Required documents at time of registration:

        Copy of US Driver’s License or US Government Photo I.D.

        If Civilian, a copy of current Concealed Weapons permit /or a statement of NO Criminal History from a Law Enforcement
Agency on Official Agency Letterhead

        Copy of current active duty, reserve, MIL/LE ID card (if applicable)

In accordance with ITAR regulations, only US Citizens are accepted to participate in Defensive Tactics & Firearms Training courses.

By submitting this application, I understand and agree:
That I must positively identify myself as the same person certified in the credentials for enrollment.

That Defensive Tactics & Firearms Training depends upon careful, physical self-control, including deadly weapons handling and
manipulation by participants, therefore I understand that my participation may be terminated at any time during the course if my
conduct is not deemed satisfactory at the discretion of the instructor.

That I will abide meticulously by any and all safety procedures required at training and that I agree to sign a statement releasing
Special Response Training, Inc. from any liability for any injury I may sustain during the training program.

PAYMENT:   Amount__________  Full Tuition is Enclosed       
Make check payable to: Special Response Training, Inc.

By submitting this application, documentation, and payment to register, I agree to the terms and conditions outlined in
the application and course description.

Special Response Training, Inc. reserves the right to refuse services to anyone at the discretion of the instructor.
LAW OFFICES OF XYZ
Your firm’s tagline goes here.
DEFENSIVE TACTICS & FIREARMS TRAINING
COURSE APPLICATION/PAYMENT
Click on PDF Link
for Application
Special Response Training
Instructions to Register
1.        Click on PDF and Print Application

2.        Complete Application

3.        Scan and Attach Completed Application And All Documentation (i.e. Copy of
         Drivers License, Gun Permit, L.E. ID) to email.

4.        Email the Above Information to
contact@specialresponsetraining.com.

5.        Complete course payment process by using the Purchase Course drop down box
         below. Click on the appropriate course and click on "Buy Now" button. Choose
         payment option and follow the instructions to complete your purchase.

6.        Please see option at checkout to use credit/debit card payment if you do not have a
         Paypal account.   

7.        Contact Us by Telephone at 706-273-6032 with any questions or to arrange other
         methods of payment. By submitting application, documentation, and payment, you
         agree to the terms and conditions outlined in the course description and application.
Purchase Course