FIREARMS SAFETY INSTRUCTOR FORM

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					                                   ST. LOUIS COUNTY POLICE DEPARTMENT
                                              STATE OF MISSOURI
                                FIREARMS SAFETY INSTRUCTOR FORM

 INSTRUCTOR NAME (Last, First, Middle)                                                            CONTACT #


 COMPANY/BUSINESS PROVIDING INSTRUCTION                                     BUSINESS ADDRESS


 CITY                           STATE                  ZIP CODE             BUS. PHONE #          FAX #


 WRITE “YES” IN ALL APPLICABLE BOXES THAT DEMONSTRATE YOUR QUALIFICATIONS AS A CERTIFIED FIREARMS
 SAFETY INSTRUCTOR AS DEFINED IN 571.111 RSMo. SUBMIT A PHOTOCOPY OF YOUR CERTIFICATE OF COMPLETION
 WITH THIS FORM
 I AM A FIREARMS SAFETY INSTRUCTOR CERTIFIED BY THE NATIONAL RIFLE ASSOCIATION HOLDING A RATING AS A PERSONAL
 PROTECTION INSTRUCTOR OR PISTOL MARKSMANSHIP INSTRUCTOR.
 I HAVE COMPLETED A FIREARMS SAFETY INSTRUCTOR’S COURSE OFFERED BY A LOCAL, STATE OR FEDERAL GOVERNMENTAL
 AGENCY, OR THE DEPARTMENT OF PUBLIC SAFETY.
 I HAVE SUCCESSFULLY COMPLETED A FIREARMS SAFETY INSTRUCTOR COURSE GIVEN BY OR UNDER THE SUPERVISION OF ANY
 STATE, COUNTY, MUNICIPAL OR FEDERAL LAW ENFORCEMENT AGENCY.
 I AM A CERTIFIED POLICE OFFICER FIREARMS SAFETY INSTRUCTOR.

                                               STUDENT INFORMATION
 NAME (Last, First, Middle)                                                                           DATE OF BIRTH
                                                                            □   MALE   □ FEMALE
 PLACE OF BIRTH                                                ADDRESS
 □ USA □ OTHER:
 CITY                                          STATE                             ZIP CODE                 HOME PHONE


                    FIREARMS SAFETY TRAINING COURSE CONTENT INFORMATION
      THE FIREARMS SAFETY COURSE WAS AT LEAST EIGHT HOURS IN LENGTH AND COVERED THE FOLLOWING TOPICS
  1     HANDGUN SAFETY IN THE CLASSROOM, AT HOME, ON THE FIRING RANGE AND WHILE CARRYING THE FIREARM.
  2     BASIC PRINCIPLES OF MARKSMANSHIP.
  3     CARE AND CLEANING OF CONCEALABLE FIREARMS.
  4     SAFE STORAGE OF FIREARMS AT HOME.
  5     THE REQUIREMENTS OF THIS STATE FOR OBTAINING A CERTIFICATE OF QUALIFICATION FOR A CONCEALED CARRY ENDORSEMENT.
  6     THE LAWS RELATING TO FIREARMS AS PRESCRIBED IN CHAPTER 571, RSMo.
  7     THE LAWS RELATING TO THE JUSTIFIABLE USE OF FORCE AS PRESCRIBED IN CHAPTER 563, RSMo.
                              DURING THE COURSE, THE STUDENT PERFORMED THE FOLLOWING
  8     PHYSICALLY DEMONSTRATED STUDENT’S ABILITY TO SAFELY LOAD AND UNLOAD A REVOLVER.

  9     PHYSICALLY DEMONSTRATED STUDENT’S ABILITY TO SAFELY LOAD AND UNLOAD A SEMIAUTOMATIC PISTOL.

 10     PHYSICALLY DEMONSTRATED STUDENT’S MARKSMANSHIP WITH A REVOLVER.

 11     PHYSICALLY DEMONSTRATED STUDENT’S MARKSMANSHIP WITH A SEMIAUTOMATIC PISTOL.

        COMPLETED A LIVE FIRING EXERCISE OF SUFFICIENT DURATION TO FIRE A HANDGUN, FROM A STANDING POSITION OR ITS EQUIVALENT, A
 12
        MINIMUM OF FIFTY (50) ROUNDS AT A DISTANCE OF SEVEN (7) YARDS FROM A B-27 SILHOUETTE TARGET OR AN EQUIVALENT TARGET.
        COMPLETED A LIVE FIRE TEST ADMINISTERED WHILE THE INSTRUCTOR WAS PRESENT OF TWENTY (20) ROUNDS FROM A STANDING
 13     POSITION OR ITS EQUIVALENT AT A DISTANCE FROM A B-27 SILHOUETTE TARGET, OR AN EQUIVALENT TARGET, OF SEVEN (7) YARDS AND
        HIT THE SILHOUETTE PORTION OF THE TARGET WITH AT LEAST FIFTEEN (15) ROUNDS.

 THERE WERE FORTY (40) STUDENTS OR LESS IN THE CLASSROOM PORTION OF THE COURSE.                   □ Yes       □ No

 THERE WERE FIVE (5) OR LESS STUDENTS PER RANGE OFFICER ENGAGED IN RANGE FIRING.                  □ Yes       □ No
 DID THE ABOVE NAMED STUDENT SUCCESSFULLY COMPLETE AND PASS THE COURSE?                           □ Yes       □ No
 I UNDERSTAND THAT IF I KNOWINGLY PROVIDE ANY LAW ENFORCEMENT OFFICER WITH FALSE INFORMATION CONCERNING AN
 APPLICANT’S PERFORMANCE ON THE LIVE FIRE EXERCISE OR TEST ADMINISTERED TO THE APPLICANT BY THE INSTRUCTOR, AS
 REQUIRED BY 571.111, RSMO., I SHALL BE GUILTY OF A CLASS “C” MISDEMEANOR.
 SIGNATURE OF INSTRUCTOR                                                                      DATE



134699 (10/03)

				
Jacquie Dore Jacquie Dore
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