Wisconsin Department Of Justice Division Of Criminal Investigation Law Enforcement Officer Safety Act Retired Law Enforcement Officer Identification Card Page 2

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CAUSES OF ACTION, DAMAGES AND/OR COSTS ARISING FROM OR IN ANY WAY
RELATING TO MY CARRYING, POSSESSING OR USING ANY WEAPON UNDER THE
PROVISIONS OF LEOSA.
I understand that this release of liability includes the release of claims for damages based on
injuries to myself or my property caused by negligent acts of the Released Parties in connection
with DCI’s LEOSA Identification Card Process. That release includes negligence involving the
Released Parties’ procedures, instructions, or conditions, or any other act related to DCI’s
LEOSA Identification Card Process. However, this release of liability does not extend to reckless
or intentional acts by the Released Parties.
I am familiar with the use of firearms and fully understand the risks and dangers inherent in the use of
firearms, including that it carries with it the risk of death or serious injury. I agree to assume the entire
risk of an accident or personal injury, including death that I might suffer as a result of my participation
in the DCI LEOSA Identification Card Process, regardless of whether such risk or injury results from
negligence of the Released Parties.
I am voluntarily participating in the DCI LEOSA Identification Card Process. I understand that it is my
responsibility to properly use my firearm.
I HAVE CAREFULLY READ THIS RELEASE OF LIABILITY AND UNDERSTAND ITS
CONTENTS. I UNDERSTAND THAT I HAVE THE RIGHT TO REQUEST DIFFERENT RELEASE
OF LIABILITY TERMS BY NEGOTIATING A SEPARATE AGREEMENT.
HOWEVER, BY
SIGNING THIS RELEASE, I WAIVE THE RIGHT TO NEGOTIATE DIFFERENT TERMS AND
AGREE TO THE TERMS CONTAINED HEREIN.
I AM AWARE THAT BY SIGNING THIS RELEASE OF LIABILITY, I AM WAIVING CERTAIN
LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE THE RELEASED PARTIES FOR DAMAGES
STEMMING FROM NEGLIGENT ACTS, AS DESCRIBED IN THE ABOVE TEXT.
By signing this Release, I certify that I have read this release and fully understand it and that I am
not relying on any statements or representations of any of the released parties.
Signature: ____________________________________________ Date: _________________
Print Full Name: _______________________________________ DOB: _________________
Address: ______________________________________________
______________________________________________
Phone: _________________________ Email: ______________________________________
P-261 / APPENDIX 3

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