APPLICATION FOR KANSAS CCH TRAINING

LaSada Sporting Clays, 3721 183rd St., Russell, KS 67665

785.483.3758www.lasada.com

NAME: __________________________________________AGE:____GENDER:____

ADDRESS: ____________________________________________________________

                    ____________________________________________________________

PHONE:  (home) ____ ____ _________ (work) ____ ____ _________  

                 (cell) ____ ____ _________

EMAIL: _______________________________

I have reviewed the Kansas Application for Concealed Handgun License and Qualifying Information (available from Sheriff’s office or www.ksag.org) and believe I can qualify.

I consider myself competent and safe in handling and shooting my handgun.  My handgun shooting experience includes __________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

I have and will bring the following items in good working order:

•One handgun (a revolver or a semi-automatic with at least 2 magazines).  It will be (Make)_____________________ (Model)_______________ (Caliber)_____

•Holster (with belt) for the handgun

•100 rounds of factory ammunition for the handgun

•Hearing protection

•Eye protection.

I will bring my Kansas Driver’s License or Kansas ID Card.

I prefer the class date:

            Alternate date:

(Please list in order of preference, you will be notified by order of receipt on availability.)

I am enclosing a check for $150.00 payable to Wallace N. Weber for the eight hour instruction fee (includes lunch, lesson materials, targets and use of range).  I understand refunds will be given if my class is cancelled by the instructor.

______________________________________

Signature/Date

Please check here ________ and indicate on reverse of form for any special needs.