MIDWEST CONCEALED CARRY_ LLC

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					           MIDWEST CONCEALED CARRY, LLC.
Please submit this form and mail your check or money order payable to
Midwest Concealed Carry. You will receive a call or e-mail with an
attachment on what you will need to bring with you. Mail your
registration form with payment to: Mark Montgomery
                                   402 W. 11th Street
                                   Cozad, NE 69130

(PRINT FULL NAME) ____________________________________________

ADDRESS: ____________________________________________________

DATE OF BIRTH: ____________________

DRIVER’S LICENSE NUMBER: __________________ STATE: ___________

CONTACT NUMBER(S): __________________________________________

E-MAIL ADDRESS: _____________________________________________

EMERGENCY CONTACT #: _______________________________________

* Please check the box below of the class you plan on attending

   Concealed Carry Course - $100.00 (Date) ___________

   Advanced Handgun Course - $60.00 (Date) __________

   Advanced Carbine Course - $60.00 (Date) __________

   Basic Handgun Course - $75.00 (Date) __________

   Private Firearm Instruction $40.00 per/hr (Date) __________

ATTENTION: NO REFUNDS! If you are unable to attend due to an
emergency and you let us know within 24 hours prior to the class, you
may be allowed to reschedule or cancel. A no show or call will not be
allowed to reschedule.

				
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