Basic Pistol Course Registration Form

Registration Form for Basic Pistol

Hello. Thank you for your interest in taking pistol safety seriously. Taking this class, passing an exam and a shooting qualification will satisfy the requirement for an in-person class so you can apply for your concealed carry permit for the State of Virginia. Please fill out the this form carefully. One form per student.
Legal Name*

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Birth Date*

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Address*

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E-mail Address*
Mobile Number*

Questionaire
Do you currently own a handgun?
Handgun Information
What is your experience with handguns?

I have never shot a handgun beforeI have shot a long time agoI have gone shooting a few times, but need assistanceI am pretty confident in my shooting abilitiesI only shoot rifles or shotguns
Which caliber gun do you own or have used in the past?

.229 mm.380.40.45revolver (.38 special or 357 magnum)rifleshotgun (12 gauge or 20 gauge)Other
Which caliber do you currently own or have used?

semi-auto: .22, 9mm, .380, .40, .45revolver: .357 or .38 specialrifleshotgunOther
Can you load a magazine and/or cylinder unassisted?
Can you rack a slide (semi-auto) unassisted?
Which is your dominant hand?
Which is your dominant eye?
Do you know how to use sight alignment and sight picture?
Can you hit a target at 5 yards?
Do you have a Conceal Handgun Permit?
CC Permit
Have you completed any handgun classes?
U.S. Citizen?*
If you are NOT a United States citizen, I cannot teach you. Please do not continue this application.
The information below is required for all applicants.
Are you under indictment or information in any court fora felony, or any other crime for which the judge could imprison you for more than one year, or are you a current member of the military who has been charged with violation(s) of the Uniform Code of Military Justice and whose charge(s) have been referred to a general court-martial?*
Have you ever been convicted in any court, including a military court, of a felony, or any other crime for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence including probation?*
Are you a fugitive from justice?*
Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance? Warning:The use or possession of marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in the state where you reside.*
Have you ever been adjudicated as a mental defective OR have you ever been committed to a mental institution?*
Have you ever been discharged from the Armed Forces under dishonorable conditions?*
Have you ever been discharged from the Armed Forces under dishonorable conditions?*
Are you subject to a court order, including a Military Protection Order issued by a military judge or magistrate, restraining you from harassing, stalking, or threatening your child or an intimate partner or child of such partner?*
Have you ever been convicted in any court of a misdemeanor crime of domestic violence,or are you or have you ever been a member of the military and been convicted of a crime that included, as an element, the use of force against a person?*
Have you ever renounced your United States citizenship?*
Are you an alien illegally or unlawfully in the United States?*
First Name* Last Name*
Driver's License Numbernumber*
Today's Date: Birth Date: date* Date*
Declaration of United States Citizenship or Permanent Residency Signature

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RELEASE AND HOLD HARMLESS AGREEMENT

I recognize and understand that there are risks associated with the use of firearms and being in proximity of their use. I voluntarily assume all risk of injury and loss from all such activities of Rebecca A Mosbrucker including any risk of injury and loss from any associated affects of sickness or disease from any class I take with Rebecca A Mosbrucker (i.e., COVID-19).

Therefore, in consideration of allowing me to participate in a safety or pistol class, for and on behalf of myself and my family, heirs, executors, administrators, successors, and assigns, I irrevocably and unconditionally release and hold harmless Rebecca A Mosbrucker and her affiliates, managers, members, representatives, agents, servants, officers, insurers, employees, successors, and assigns, from any and all liability for all claims, damages, losses, and injuries that I might suffer or incur from all causes whatsoever as a result of participation in all events held, sponsored, or endorsed by Rebecca A Mosbrucker, including but not limited to all losses caused wholly or in part by the negligence of Rebecca Mosbrucker or any other person or entity for whose acts or omissions could be held responsible or liable in any manner.
Further, for and on behalf of myself and my family, heirs, executors, administrators, successors, and assigns, I covenant and agree not to sue Rebecca Mosbrucker and her affiliates, managers, members, representatives, agents, servants, officers, insurers, employees, successors, and assigns for any injury and loss that arises from or results from my conduct or the conduct of another or arises from or results while participating in or attending any event held, sponsored, or endorsed by Rebecca Mosbrucker.
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Permission to Use Photograph

I grant to Rebecca Mosbrucker, her representatives and employees, the right to take photographs of me and my property in connection with the above-identified subject. I authorize Rebecca Mosbrucker, her assigns and transferees to copyright, use and publish the same in print and/or electronically.
I agree that Rebecca Mosbrucker may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.
Hold Harmless Agreement Signature

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Date*

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Date

What I will teach you in this course:

Basic parts of a semi-auto and revolver and how they workAmmo and how it works with your firearmHow to hold a firearmLearn the correct stance for youHow to sight in a firearmHow to breathe during shootingHow to store your firearmHow to clean your firearmHow to score a targetConceal carry discussion optionsAND MORE...
What should you bring to class?
Basic Pistol Courses Available - 1/30/2021
Date of next class: 1/29/2022.
Date of next class: 5/19/2024
Date of next class: 1/18/2025
Date of next class: 2/22/2025
Date of next class: 3/12/2022.
Quantity for 7/19/2025
Quantity for 5/4/2025
Quantity for 6/8/2025
Quantity for 9/17/2022
Quantity for 9/27/2022
Quantity for 10/3/2022
Quantity for 1/28/2023

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Basic Pistol Deposit

Basic Pistol Range Fee

Private Instruction

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USCCA Concealed Carry and Home Defense Product Image

USCCA Concealed Carry and Home DefenseThis is a USCCA class. It will cover conceal carry issues and how to defend your home.

$100.00 Quantity
Item subtotal:$0.00

Race Friends Cain

$ Free

Basic Pistol Deposit

NRA Basic PistolNon-refundable deposit of $150.00 due upon submittal of application to reserve your spot.

$150.00 Quantity
Item subtotal:$0.00

Basic Pistol Range Fee

Use of My Personal Firearms and Ammo Product Image

Use of My Personal Firearms and AmmoIf you don't have a firearm and need to rent one from me, you can do that with one of my firearms at a fee of $50 (this will include 50 rounds of ammo). If extra ammo is needed, you will need to purchase that. I have a .22, a .380 and a 9mm that I rent out.

$50.00 Quantity

Extra Trips to the Range for Qualification Product Image

Extra Trips to the Range for QualificationIf travel to the range for more than one trip for qualification, an extra fee of $25.00 will be billed.

$35.00 Quantity

Private Instruction

Private Class Instruction w/RangeThis is the fee for Private Instruction = classroom and range.

$150.00

Consulting

Business ConsultingPlease email me the details of your request. This fee is per hour and due upon submittal of application.

$75.00

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Registration Form for Basic Pistol

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