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.
* Means Required Field:
*
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
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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
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1959
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1961
1962
1963
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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
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
*
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.