Pistol Complete Certification Form 2020 Pistol Re-Qual Certifications Firstname * Lastname * Member No. * Email Appt Date Appt Time RELEASE OF LIABILITY INDOOR/OUTDOOR/PISTOL RANGE AND PLATE RACK AUTHORIZATION I, do hereby state: I have read and fully understand all rules pertaining to the use of the indoor/outdoor pistol ranges and the plate rack 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. 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 Indoor/Outdoor Range, Plate Rack and Pin RangeQualification Checklist Range Safety Officer must check-off each item below, check off Pass or Fail and sign form below. Verified 1 Instructor demonstrates and/or explains: proper use of lighting, ventilation and heating system and the sign in process use eye, ear protection and ball cap within the range shooting area maximum target size for the indoor range proper use of the IN door and OUT door no handling of guns in the ready room; can load magazines 1 lane for guests, member observes guest 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 or decocker 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: score 8 out of 10 hits on the target in a proper and safe manner Verified 5 Member must understand on the outdoor range: the use of the RED FLASHING light and the ORANGE line on the cement pad maximum targets, size, placement and initial shot placement sweeping area before leaving Verified 6 Instruct members on the rules all must use when shooting on the plate range Verified 7 Instruct members on the rules all must use when shooting on the bowling pin range 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 indoor/outdoor and plate rack range rules. The member is authorized to use the indoor/outdoor pistol range and the plate rack. 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 fisher goetz hall hankey hunter johnston jones joyce koury 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.