APPLICATION / REGISTRATION FORM

(GSRGO Seminar & Proficiency Firing)

______________________

Date

NAME: ________/_______________________________________________________(Name Prefix) First Name) (Middle Name) (Last Name)

ADDRESS: _____________________________________________________________

(Nr.) (Street) Municipal City Province

DATE OF BIRTH: ___________________ PLACE OF BIRTH: ___________________

CONTACT Nos.: ___________________________/_____________________________

BUSINESS / OCCUPATION: _______________________________________________

BUSINESS ADDRESS: _______________________________ TEL. No. ___________

Purpose of Seminar: LTOPF Other: ______________________________ (Please Specify Purpose)

SEMINAR: ________________________________________________/____________

SHOOTING:_______________________________________________/____________

FIREARM/S DESCRIPTION: (If any)

TYPE: _________ MAKE/MODEL: ______________________________ CAL: _____

I, the UNDERSIGNED, shall not hold CPPSA INC.

(Cppsa Gun Club) and its personnel liable for any CRIMINAL

or CIVIL LIABILITY out of any injury or untoward incident

upon myself and to any third party that my occur during this

seminar due to my negligence, carelessness or imprudence.

(Signature of Applicant inside the box only)

2 X 2 Recent

Photo

____________________ (Signature of Witness)

(Name & Address of Shooting Range where Shooting Proficiency held)

(Date)

if Desired

EXAM

SCORE

Passed

Failed

WAIVER

Note: I understand that written EXAM & Proficiency Shooting

exercises has only (3) THREE TIMES TRIAL, otherwise

I have to re-register again.

(Date)

(Date)(Name & Address where Seminar held)

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