Register for Courses

Name*

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Address*

Street Address City State ZIP Code

Email*

Phone*

Number of people taking the course*

Please enter a number from 1 to 100.

Preferred days and times and any comments

Please choose which course(s) you wish to take

Driver License #

ID will be required for all courses

Issuing State

Date of Birth*

1. Are you prohibited by law from owning or possessing a firearm?*

Yes
No

2. Are you under the indictment for a crime punishable by imprisonment for a term exceeding one year?*

Yes
No

3. Have you been convicted of a crime punishable by imprisonment for a term exceeding one year?*

Yes
No

4. Have you ever been adjudicated mentally defective or have you been committed to a mental institution?*

Yes
No

5. Have you ever renounced your United States citizenship?

Yes
No

6. Have you been convicted in any court of a crime of misdemeanor domestic violence?*

Yes
No

7. Are you subject to a court order restraining you from harassing, stalking, or threatening an intimate partner or child of such partner?*

Yes
No

8. Have you been discharged from the Armed Forces under dishonorable conditions?*

Yes
No

9. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance?*

Yes
No

Are you a citizen of the United States? If not what country do you have citizenship?*

Yes
No

By pressing submit I certify that the above answers are true and correct and that I am of good moral character. I understand that a person who answers “yes” To any of questions 1-9 is prohibited from possessing a firearm. Furthermore, I or my agent(s), assigns, executors or administrators, for the consideration of being allowed to enter, rent and use the facilities, firearms and services at Burlingame scuba center, bay area firearms instruction company, Scott Jackson, and for the valuable consideration to hereby absolutely and unequivocally agree to release and save harmless, bay area firearms instruction company, Scott Jackson, Burlingame scuba center, its agents, employees, instructors, my instructors assigns from any claim demand or liability whether claimed by myself or another arising out of injury, loss or disability connected with above facilities and services, including but not limited to damage or injury resulting in clearing of a customers jammed or malfunctioning firearm by either my instructors, Scott Jackson, bay area firearms instruction company, or authorized agents.
If patron is under 18 the form must be filled out by a parent or guardian.

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