©Fraternal Order of Police WA1, (2014)

Last Name, First MI Agency Retired Date Badge or ID#

Address City and State

Phone EMAIL

FOP Member # SIGNATURE

Deposit Required $20, Payment in full: Non-Member $50.00)

REGISTRATION Please submit this completed form via email to one of the addresses below or mail to: FOP, P.O. 3189, Silverdale, WA, 98383-3189, make checks payable to: FOP Evergreen 1. Email applications will not be accepted without payment verification via PAYPAL (see below link.) Mailed in application MUST be received no later than 2 working days prior to the event. Pre-registration is strongly encouraged as this event may fill quickly. While you may bring this form and payment on the day of the event, you will not be registered or guaranteed a reserved slot to qualify. You may pay the non-refundable deposit or pay in full via PAYPAL prior to the date of the event with full payment due at the day of the event. Register at: http://www.fopevergreenlodge.org/Events.html For more information email FOPLodge1WA@comcast.net

QUALIFICATION: This is a timed course of fire is as required by the Washington Criminal Justice Training Commission consisting of 25 rounds fired from 3 to 15 yards using the BLEA-2 target. Minimum qualifying score is 175. You may qualify with multiple weapons and/or as many times as necessary at the discretion of the Range Master and/or subject to time constraints placed on range use by the host range. See the Course of Fire on the attached Qualification Form. Successful participants will be issued a signed wallet card.

PARTICIPANT REQUIREMENTS: Shooters shall bring their own firearms and ammunition, hearing and eye protection. (Recommend at least 50 rounds of ammunition per qualifying weapon.) For safety purposes, only factory-loaded ammunition will be allowed for use during this qualification.

Please bring sufficient loaded magazines and/or speed-loaders to accomplish 25 round qualifications without delays and interruptions of other participants. All firearms must be in good working order and will be inspected by staff prior to qualifications. Unsafe or illegally modified firearms are not permitted.

Belt slide, pancake, or paddle holsters are recommended. Soft (unreinforced) inside the waist band holsters are not recommended and may cause delays re-holstering during timed shooting events. No cross-draw, shoulder holsters, or ankle holsters will be permitted.

Deliberate unsafe acts will result in non-qualification and ejection from the range and forfeiture of fee.

Dress appropriately for the weather, wear comfortable clothing, but not that would interfere with ability to draw and/or holster a weapon.

REQUIRED CREDENTIALS: You must bring your Agency-issued credentials indicating you are “Retired” in good standing or otherwise meet the requirements of 18 USC 926C, and are eligible to carry; or are not disqualified from carrying a firearm. For military police officers; bring your DD Form 2 (Retired ID) and certified DD214 indicating you retired in one of the following Military Occupational Specialty codes and /or Officer Designator Codes; 31A-Officer, 31B-Enlisted and 31D-CID (Army), NOD 649 and 749, Master-at Arms Enlisted Rating (Navy), 5803, 5805-Officer, 5811, 5819, 5821-Enlisted (USMC), 31PX, S1SX-Officer, 3POX1-Enlisted (USAF). Coast Guardsmen Officers and enlisted designated as LE. All applicants must not be under any restrictions (Lautenberg) from possession of a firearm. *This event subject to change or cancellation dependent upon number of participants, refunds will be made for deposits if cancelled by FOP.

RELEASE OF LIABILITY All participants will sign a release of liability at the time of the event.

LEOSA Handgun Qualification Course Registration

LEOSA Retired Law Enforcement Officers

INSTRUCTIONS: Unless otherwise directed the officer will begin each position of fire with handgun holstered and any retention devices properly secured.

Scoring of the course is based on the BLEA Tactical or similar type target. Any miss off the silhouette will result in a ten-point penalty for each. Hits on the silhouette but outside the scored area of the target and DNF’s (Did Not Fire) will result in zero points, but will not be penalized. Two hits are required in the Target Head, more or less than two hits will result in zero points for each additional round or missed round. (Revised 01 /31/14)

OFFICERS NAME: (LAST), (FIRST) (MI) AGENCY ID NUMBER SESSION #:

HANDGUN MAKE, MODEL, CALIBER

TYPE OR MANNER OF CARRY

SEQUENCE DISTANCE DESCRIPTION SHOTS TIME 1 3 Yards Draw and fire 4rds. (2 Body, 2 Head). Un-timed reload. 4 7 seconds

2 5 Yards Draw and fire 3rds using strong-hand only. Un-timed reload. 3 5 seconds

3 5 Yards From a Ready position, fire 3rds using support-hand only. Un-timed reload. 3 7 seconds

4 7 Yards From a Ready position, fire 5rds. Un-timed reload. 5 9 seconds

5 10 Yards From a Ready position, fire 5rds. Un-timed reload. 5 12 seconds

6 15 Yards From a Ready position, fire 5rds. Un-timed reload. 5 12 seconds

Total shots 25

INITIAL SCORE (BLEA MINIMUM; 175 PTS = 70%)

FINAL TEST SCORE PERCENTAGE

I HEREBY CERTIFY THAT THIS BASIC HANDGUN PROFICIENCY COURSE WAS ADMINSTERED TO THE OFFICER AND THAT THE OFFICER’S POINT SCORE HAS BEEN FULLY AND ACCURATELY RECORDED HEREON.

_______________________________________ ________________________________________ Name of certifying officer, (Print Name). Signature of certifying officer. _______________________________________ ________________________________________ Agency & position of certifying officer. Date and location of test.

On the silhouette - outside the scored area No Penalty Off silhouette – 10 Point Penalty

LEOSA Retired Law Enforcement Officers

INSTRUCTIONS: Unless otherwise directed the officer will begin each position of fire with handgun holstered and any retention devices properly secured.

Scoring of the course is based on the BLEA Tactical or similar type target. Any miss off the silhouette will result in a ten-point penalty for each. Hits on the silhouette but outside the scored area of the target and DNF’s (Did Not Fire) will result in zero points, but will not be penalized. Two hits are required in the Target Head, more or less than two hits will result in zero points for each additional round or missed round. (Revised 01 /31/14)

OFFICERS NAME: (LAST), (FIRST) (MI) AGENCY ID NUMBER SESSION #:

HANDGUN MAKE, MODEL, CALIBER

TYPE OR MANNER OF CARRY

SEQUENCE DISTANCE DESCRIPTION SHOTS TIME 1 3 Yards Draw and fire 4rds. (2 Body, 2 Head). Un-timed reload. 4 7 seconds

2 5 Yards Draw and fire 3rds using strong-hand only. Un-timed reload. 3 5 seconds

3 5 Yards From a Ready position, fire 3rds using support-hand only. Un-timed reload. 3 7 seconds

4 7 Yards From a Ready position, fire 5rds. Un-timed reload. 5 9 seconds

5 10 Yards From a Ready position, fire 5rds. Un-timed reload. 5 12 seconds

6 15 Yards From a Ready position, fire 5rds. Un-timed reload. 5 12 seconds

Total shots 25

INITIAL SCORE (BLEA MINIMUM; 175 PTS = 70%)

FINAL TEST SCORE PERCENTAGE

I HEREBY CERTIFY THAT THIS BASIC HANDGUN PROFICIENCY COURSE WAS ADMINSTERED TO THE OFFICER AND THAT THE OFFICER’S POINT SCORE HAS BEEN FULLY AND ACCURATELY RECORDED HEREON.

_______________________________________ ________________________________________ Name of certifying officer, (Print Name). Signature of certifying officer. _______________________________________ ________________________________________ Agency & position of certifying officer. Date and location of test.

On the silhouette - outside the scored area No Penalty Off silhouette – 10 Point Penalty