Registering For: Todays Date: 9/24/2018
    Are you a disabled shooter:
Class Date: Are you pregnant? If yes, contact instructor and DO NOT complete form
Participant Information
First Name: Marrital Status:
Middle Name: Place of Birth:
Last Name: Age:
Is this your legal name? Height:
If not, please enter legal name: Weight:
Country of Citizenship : United States Other (Specify) Sex: Male Female
Alien Number:  
Street Address: Date of Birth: / /
PO Box Home Phone Number:
City: Occupation:
State: Employer:
Zip: Employer Phone:
Email Address:  
I understand I must provide my own firearm and ammunition for this course.  
What Type of Firearm: Revolver:
Semi-Automatic:
   
How did you hear about this course. Family Friend Community Flyer Google/Internet Other  
Describe in full detail (including military History) your pistol shooting/handling experiences.  
 
No
1.
Are you under indictment or information in any court for a felony, or any other crime, for which the judge could imprison you for more than one year? (See Instructions for Question 1)
No
2.
Have you ever been convicted in any 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?  (See Instructions for Question 2)
No
3.
Are you a fugitive from justice?
No
4.
Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance?
No
5.
Have you ever been adjudicated mentally defective (which includes a determination by a court, board, commission, or other lawful authority that you are a danger to yourself or to others or are incompetent to manage your own affairs) OR have you ever been committed to a mental institution? (See Instructions for Question 5)
No
6.
Have you been discharged from the Armed Forces under dishonorable conditions?
No
7.
Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an intimate partner or child of such partner?  (See Instructions for Question 7)
No
8.
Have you ever been convicted in any court of a misdemeanor crime of domestic violence?  (See Instructions for Question 8)
No
9.
Have you ever renounced your United States citizenship?
No
10.
Are you an alien illegally in the United States?
No
11.
Are you an active Michigan Medical Marihuana Program card holder?     If Yes: Disclaimer:  I acknowledge that I am an active card holder for the Michigan Medical Marihuana Program and have personally decided to proceed with paying for and taking the Buck Wild Nation Training Institute, Concealed Pistol License firearm training course.  I understand that should my application for a Michigan Concealed Pistol License be DENIED by the State of Michigan, I will not be reimbursed the cost of this firearm course provided by Buck Wild Nation Training Institute and I will hold the instructor harmless from any State of Michigan decision to deny my Concealed Pistol License application.  I further understand that there is a high potential that I will be denied a Michigan Concealed Pistol License if I am an active card holder in the Michigan Medical Marihuana Program
Please indicate any questions or remarks in this section.    

Question 1 Instructions:  Under Indictment or Information or Convicted in any Court:  An indictment, information, or conviction in any Federal, State, or local court.  An “information” is a formal accusation of a crime verified by a prosecutor.

Question 2 and 8 Exceptions:  A person who has been convicted of a felony, or any other crime, for which the judge could have imprisoned the person for more than one year, or who has been convicted of a misdemeanor crime of domestic violence, is not prohibited from obtaining a CPL if: 1) under the law of the jurisdiction where the conviction occurred, the person has been pardoned, the conviction has been expunged or set aside, or the person has had their civil rights (the right to vote, sit on a jury, and hold public office) taken away and later restored AND 2) the person is not prohibited by the law of the jurisdiction where the conviction occurred from receiving or possessing firearms.  Persons subject to this exception should answer “no” to question 2 and 8, as applicable.

Question 5 Instructions:  Adjudicated Mentally Defective:  A determination by a court, board, commission, or other lawful authority that a person, as a result of marked subnormal intelligence, or mental illness, incompetency, condition, or disease: 1) is a danger to himself or to others; or 2) lacks the mental capacity to contract or manage his own affairs.  This term shall include: 1) a finding of insanity by a court in a criminal case; and 2) those persons found incompetent to stand trial or found not guilty by reason of lack of mental responsibility.  Committed to a Mental Institution:  A formal commitment of a person to a mental institution by a court, board, commission, or other lawful authority.  The term includes a commitment to a mental defectiveness or mental illness.  It also includes commitments for other reasons, such as for drug use.  The term does not include a person in a mental institution for observation or a voluntary admission to a mental institution.  Please also refer to Question 2 Instructions for definition of a prohibited person.

Question 5 Exceptions:  NICS Improvement Amendments Act of 2007:  A person who has been adjudicated as a mental defective or committed to a mental institution is not prohibited if:  1) the person was adjudicated or committed by a department or agency of the Federal Government, such as the United States Department of Veteran’s Affairs (“VA”) (as opposed to a State court, State board, or other lawful State authority), and 2) either; a) the person’s adjudication or commitment for mental incompetency was set-aside or expunged by the adjudicating/committing agency; b) the person has been fully released or discharged from all mandatory treatment, supervision, or monitoring by the agency; or c) the person was found by the agency to no longer suffer from the mental health condition that served as the basis of the initial adjudication.  Persons who fit this exception should answer “no” to Question 5.  This exception does not apply to any person who was adjudicated to be not guilty by reason of insanity, or based on lack of mental responsibility, or found incompetent to stand trial, in any criminal case of under the Uniform Code of Military Justice.

Question 7 Instructions:  Definition of Restraining Order:  Under 18 U.S.C. 922, a CPL may not be issued to persons subject to a court order that: A) was issued after a hearing which the person received actual notice of and had an opportunity to participate in: B) restrains such person from harassing, stalking, or threatening an intimate partner or child of such intimate partner or person, or engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury to the partner or child; and C) (i) includes a finding that such person represents a credible threat to the physical safety of such intimate partner or child; or (ii) by its terms explicitly prohibits the use, attempted use, or threatened use of physical force against such intimate partner or child that would reasonably be expected to cause bodily injury.  An “intimate partner” of a person is:  the spouse or former spouse of the person, the parent of a child of the person, or an individual who cohabitates or cohabitating with the person.

Question 8 Instructions:  Definition of Misdemeanor Crime of Domestic Violence:  A Federal, State, local or tribal offense that is a misdemeanor under Federal, State, or tribal law and has, as an element, the use of attempted use of physical force, or the threatened use of a deadly weapon, committed by a current or former spouse, parent, or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with, or has cohabited with the victim as a spouse, parent, or guardian, or by a person similarly situated to a spouse, parent, or guardian of the victim.  The term includes all misdemeanors that have, as an element, the use or attempted use of physical force or the threatened use of a deadly weapon (e.g. assault and battery), if the offense is committed by one of the defined parties (See Exception to Question 8).  A person who has been convicted of a misdemeanor crime of domestic violence also is not prohibited unless: 1) the person was represented by a lawyer or gave up the right to a lawyer; or 2) if the person was entitled to a jury, was tried by a jury, or gave up the right to a jury trial.  Persons subject to this exception should answer “no” to Question 8.

In case of Emergency
Name of Relative: Relationship:
Home Phone: Cell Phone:
       
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize or insurance company to release any information required to process my claims.
Payment Information
Class Fee    
       
You must pay a mandatory $20 on the completion of this application and bring the balance in the form of cash or check to the class . Make checks payable to "Buck Wild Training Institute"
Participant Electronic/Signature (By signing or typing your name and clicking on the “Submit Form” button, I understand that my course registration is not final until confirmed by the instructor via email or telephone contact after review of my registration form).
Type Name: Date: