Your Contact Information

First Name: Middle Init.: Last Name: Phone:

Street Address:

City: State: Zip Code: DOB:

Email Address:

Are you an NRA Member? Yes No         

If you answered Yes to the above please enter your NRA ID number:

Are you Registered with the BSA? Yes No --- Council District:

If you are registered with the BSA please enter your ID number:

Are you a Member of:

Beaverbrook Sportsman's Club? Yes No

If you are a Beaverbrook Member please enter your member number:

Course Selection
NRA Range Safety Officer (October 14)        This class is at Beaverbrook Sportsman's Club --- East Bethel.