Register - Ed Jean

First Name

Middle Name

Last Name

Suffix (Ex. Jr., II, III)

Maiden Name

Name you go by

Residence Address

holster? (Ex. text,

City

State

Zip

County

Social Security # (you can send to me via phone or text, if desired)

DL/ID Card #

Alien # (Green Card number, if applicable)

Date of Birth (YYYY/MM/DD)

Place of Birth (City, State)

Race

Height

Weight

Eye Color

Hair Color

Home Phone

Business Phone

Cell Phone

Email

Are you a SC resident or qualified non-resident?

Yes
No

Are you allowed by ALL applicable federal/state laws and court orders to possess a handgun?

Yes
No

Check if any of the following apply

Do you have a pistol for the class?

Yes
No

If yes, please indicate make, model & caliber

Do you have a pistol specific holster?

Yes
No

If yes, please describe construction type

Special Needs

If you have any special needs, or physical, medical, mental, or other condition that might require accommodations or of which we need to be aware, please let us know in writing below. These things DO NOT preclude you from taking this course, but knowing about any issues can help us better meet your needs and help you get the most out of the course. Examples: diabetes, epilepsy, asthma, heart conditions, problems gripping (arthritis, missing or malformed digits, etc.), problems standing (require wheelchair/cane/walker, etc.), attention issues, prior traumatic experience with firearms or violence, hearing issues, etc.

Emergency Contact (Name, Phone No. & Relationship)