Register – Basic Firearms Safety – Ashland, Va.
Student Registration
Name
(required)
Street Address
(required)
City
(required)
State
(required)
Zip Code
(required)
Primary Phone
(required)
Secondary Phone
Email
(valid email required)
How did you hear about Proactive Shooters?
(required)
Course Selection
Course Date
Choose Class Date:
Saturday, September 25, 2010 11am-4pm
Sunday, October 10, 2010 11am-4pm
Saturday, November 13, 2010 11am-4pm
Saturday, December 11, 2010 11am-4pm
(required)
Person to Notify in Case of Emergency
Name
(required)
Primary Phone
(required)
Secondary Phone
Safety Class - Certificate of Completion
Please indicate how you would like your name to appear on your certificate. Example - John Smith, John J. Smith, John J. Smith Jr.
Name
(required)
IMPORTANT - You must click "SUBMIT" to send your registration. You will then be redirected to the "Pay Now" button to make your payment with your Visa, Mastercard, Discover, American Express, electronic check or Paypal account. If you wish to pay in another manner, you may do so by contacting our offices to make arrangements.
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Please Do Not click Pay Now Until AFTER You Submit your form data!
