Pplication For Mandatory Firearms Training Form - Central Illinois Police Training Center

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APPLICATION FOR MANDATORY FIREARMS TRAINING
at
(CENTRAL ILLINOIS POLICE TRAINING CENTERMTU #7)
PUBLIC ACT 79-652
Department Name:
Department Address:
(City, State and Zip Code)
Department Telephone Number:
Applicant's Name:
(Last Name, First Name, Middle Initial)
Birth Date:
Appointment Date
Employment Status:
☐Full-time
☐Part-time
☐Auxiliary
PTB#
Last 4 SSN#
FOID CARD #
Expiration Date
Duty Weapon:
Make
Model #
*NOTE: ONLY Factory New or Reputable Factory Reloads are authorized for use on the Range. Student
enrollment will not be considered without this completed application and copy of completed Form E card.
Students must be employed as either a full-time, part-time or auxiliary officer at a police department. A
supervising official of the local government entity or official of the agency involved who has legal power
must register the student. (Mayor, Village Board President, County Board Chairman, Chief or Sheriff)
I certify the above named applicant is a police officer of the aforementioned department/agency for
the city/county of
.
The applicant will attend the
Mandatory Firearms Training course on the following date(s):
The city/county assumes all liability and relieves all sponsoring agencies, all participating
instructors and the Central Illinois Police Training Center Mobile Team Unit #7, from all legal
responsibility due to any part of this Mandatory Firearms Training.
__________________
Administrator of the Agency
(Signature)
Date
**MAIL completed application form and e card, to:
Central Illinois Police Training Center
Illinois Central College North Campus
5407 N. University Poplar Hall P100A
Peoria, IL 61614
Phone: 309/690-7350
Revised Form
2/2016
MOBILE IN-SERVICE TRAINING TEAM #7
ILLINOIS LAW ENFORCEMENT TRAINING AND STANDARDS BOARD

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