2020 AS Long Gun Certification 2020 NOT USED ASLG Re-Qual Certifications Firstname * Lastname * Member No. * Email * AS Qualification Type Appt Date Appt Time RELEASE OF LIABILITY ACTION SHOOTING LONG GUN/SHOTGUN AUTHORIZATION I, do hereby state: I have read and fully understand all rules pertaining to the use of the Action Shooting Ranges located at the Chester Rod and Gun Club (CRGC). I am familiar with the safety procedures and rules of safe firearm handling. I agree to abide by all rules and regulations at CRGC; and, understand failure on my part to due so may result in revocation of these privileges. I agree that my participation in this activity/event, or any other activity/event/contest conducted by CRGC, is purely voluntary and represents a possible hazard to me due to the use of firearm equipment in a sporting endeavor. I assume all risk freely and hold all persons and/or businesses associated with this or any other event/contest I may participate in at CRGC, to be blameless in case of injury and/or death during this or any other event/contest. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Chester Rod and Gun Club. Acceptance I Accept. Member eSignature Acceptance Date Range Safety Officer must check-off each item below, check off Pass or Fail and sign form below. Action ShootingLONG GUN/SHOTGUN Qualification Checklist Verified 1 Instructor demonstrates and/or explains: Use eye, ear protection within the Action Shooting Ranges.No handling of guns in parking area, must be in range area safely aimed at berms or at safety tables,No ammo handling at safety tables.Shooting Long Gun alone is permissible, but when shooting two or more one member must act as the RO while shooting.Range officer function.Clean-up process. Verified 2 Member must demonstrate knowledge of: general operation of firearm (verbal only, do not load at this point). loading and unloading (verbal only, do not load at this point). position and operation of safety. Verified 3 Member must demonstrate firearm/range safety: firearm must always be pointed in a safe direction. finger must not be within trigger guard until on target and ready to shoot. firearm must be open and unloaded on the firing line until ready to shoot. Verified 4 Member must demonstrate firing the firearm "either Rifle or Shot gun to qualify": Rifle - Distance 20 yards5 of 14 shots in the “A zone” remaining shoots must be in “A” or “C” zone & able to show firearm clear when completed.Semi-auto only.Shot Gun - Distance 15 yards. 3 shots reload 3 shots on steel, must be able to show firearm clear when completed.5 out of 6 targets must fall.If firing is complete, firearm must be bagged correctly (Flagged also if available). Verified 5 Member must understand in the Action Shooting Ranges: Location of target placement, types of targets and initial shot placement. Cleaning / Picking up area before leaving. Notifying AS committee of any damage found. Verified 6 Instruct members on the rules that must be used when shooting in the Action Shooting Ranges. Verified 7 Written test completed and scored 90% or greater, Review all incorrect answers. RSO Attestations The undersigned club official has verified the above-named person is checked out in the use of firearms handling. The member is handed a copy of the Action Shooting rules. The member is authorized to use the Action Shooting Ranges with a LONG GUN and given an "AS2" sticker to place on their CRGC membership badge. Qualification Type New Member Re-Qualification Outcome Pass Fail Sticker Issued Yes No Input into SK-Net Yes No RSO eSignature abramovitch anderson armstrong begley brown campbell carney charest coffill del tufo denison English fisher goetz hall hankey hunter johnston jones joyce koury LaLiberte laliberte litterer madden madea maher mckenna mulchahey o'connell o'neill prouty retzke rookey sverker taylor thompson torrisi treat welch Young Select Certifier's LASTNAME RSO Badge No. Date Qualified RSO Notes Submit If you are human, leave this field blank.