Continuation Of Certification Annual Firearms Training Report Form - New Mexico Department Of Public Safety Training Center

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New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251―(877) 237-7532 (NM Only) ―Fax: (505) 827-3449―
CONTINUATION OF CERTIFICATION
ANNUAL FIREARMS TRAINING REPORT
Pursuant to DPS LEA Rule 10.29.9.14, the listed individual has met the firearms re-qualification requirements
as noted:
Name_______________________________________________________________________
Last
First
Middle
Date of Birth ________________SSN______________________Gender_________________
NM State Law enforcement Certification #:_________________________________________
Home Address:_______________________________________________________________
City______________________________State_____________________Zip______________
Contact Number: _______ -_______________________ Email:__________________________
Official State of NM DPS Qualification Course Scores:
Date
Day
Night
Make
Model
Serial Number
Time
Time
Score
Score
Range facility (Agency/Location):
Print or Type Name)
DPS Certified Instructor (
DPS Firearm Instructor Certification Number
________________________________________
________________________________________
I hereby certify that I am a certified NM Department of Public Safety Firearms Instructor and the above
firearms qualification scores are true and correct.
Instructor Signature_______________________________
Date_____________________________
Contact Number: _______-__________________________
E-mail___________________________
Registry Input by:
Instructor Certification Verified by:
Firearms Qual. Processed by:
Revised 01-17-12
LEA-85

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