Please fill out the application form completely and accurately. A mandatory criminal background check is required. This check must be completed prior to your visit. * Required:

*First Name
*Last Name
Middle initial
*Email
Occupation
*Address 1
Address 2
Apt #
*City
*State
*Zip
*Contact Ph #
*Date of Birth	-- Month -- January February March April May June July August September October November December -- Date -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- Year -- 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991
*Proof of ID (enter number)	-- State -- NY NJ CT PA AL AK AS AZ CA CO AR DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NM NC ND OH OK OR RI SC SD TN TX UT VT VA WA WV WI WY USA Canada UK International Other -- Type -- Drivers License Non Drivers ID Passport Mil. / LE ID Other
Referral	-- Please Select -- Google Search Yahoo Search Daily News Events Yelp CitySearch WSSL Chelsea Pratt Art Show Radio Newspaper Ad Friend Groupon, Living Social, Zozi, etc. Other
Group Leader Email	Only approvals will be copied to Group Leader if entered.
I consent to Westside Rifle & Pistol Range and/or its agents or vendors conducting a criminal background check on me using the information I have supplied in this application.