International Shootists Institute

Name: _________________________________Date of Birth: _______________________

Address: __________________________City: ________________Zip: ________________

Home Phone #: ___________________________Work Phone #: _____________________

Certification For Training

An untruthful answer may subject you to termination of training. Each question must be answered with a "yes" or "no".

1. Are you under indictment or information in any court for a crime punishable by imprisonment for a term exceeding one year? _____
2. Have you been convicted in any court of a crime punishable by imprisonment for a term exceeding one year? _______
3. Are you a fugitive of justice? _______
4. Are you an unlawful user of , or addicted to, marijuana or a depressant, stimulant or narcotic drug? _________
5. Have you ever been adjudicated mentally defective or have you ever been committed to a mental institution? ________

I hereby certify that the answers to the above are true and correct. I understand that a person who answers any of the above questions in the affirmative prohibited from training.

I hereby state that I have no physical or medical problems that would preclude me from participating in shooting instruction and training.

Any student who does not comply fully with the safety standards will be expelled from the course and his/her tuition will be forfeited.

Your Profession _____________________________________.

What type and caliber of firearm you will be using _____________________________.

Signature ____________________________ Date __________________________.