Form F-9r - Retired Law Enforcement Officer Firearms Qualification Application Page 2
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2Training and Qualification Certification
Dates of Firearms Qualification: ______________________________________________________________
Location: __________________________________________________________________________________
Name of Facility
City
Instructor’s Name:
_________________________________________________________________________
Instructor’s Certification Number: _______________________ Date of expiration:
___________________
(located on instructor certificate)
Weapon(s) qualified with:
1) ____________________________________________
2) ____________________________________________
Make
Model
Make
Model
____________________________________________
_________________________________________________________
Day Score
Night Score
Day Score
Night Score
________________________________________
_________________________________________
3)
4)
Make
Model
Make
Model
____________________________________________
_______________________________________________________
Day Score
Night Score
Day Score
Night Score
As a certified Specialized Firearms Instructor, I hereby attest that the above named applicant has successfully
completed the North Carolina Criminal Justice Education and Training Standard Commission’s “Retired Law
Enforcement Officers Firearms Qualification Certification Course” as prescribed in 12 NCAC 09H .0102 of the
North Carolina Administrative Code and has successfully qualified with the handgun(s) indicated above.
__________________________________________________________________________________________
Instructor’s Signature
Date
Application Process
The original completed and notarized application must be submitted along with the following attachments:
$ A copy of your photographic identification indicating retirement status issued by the law enforcement agency
from which you retired; and
$ A certified check or money order for certification fees made payable to the North Carolina Department of
Justice. [$50.00 for an initial one-year qualification application or $25.00 for an annual renewal application].
The completed application, required supporting documentation and fees should be submitted to:
Criminal Justice Standards Division
North Carolina Department of Justice
P.O. Drawer 149
Raleigh, NC 27602
Form F-9R (8/09) p.2
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