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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