High-lite the following "Application and Hold-Harmless Document" then print
using the "SELECTION" option -or- paste to your word document.
Application and Hold-Harmless Document
Print your full name:_________________________
Home telephone number: (_____)_____-__________
Street Address: ______________________________
City, State, Zip-code:________________________
Work Telephone Number: (_____)_____-__________
Social Security Number: _______-_____-_________
Date of Birth: _____/_____/_____
Name of person to contact in an emergency:________________
Emergency Contact Telephone Number:(_____)_____-__________
Your e-mail address: ___________________@_____________.com
Last School attended -- Degree(s) -- Diploma(s) received:______________________________
Current or past employment or retired from what?:_____________
Request: (___) 8 hour CCW course (___) 2 hour Refresher CCW Course
(expires)___/___/___ (___) Other:
How did you hear about us? (Which newspaper, Yellow pages, Word of mouth, Other?)
_______________________________________________
I hereby agree to defend, indemnify and hold harmless Collier's Ex-Caliber Inc., a.k.a. Collier's X-Calibre
("CXC"), its officers, directors, servants, agents and employees from and against any and all losses, damages,
claims, liabilities, and judgments, including costs and expenses incident thereto, which may be charged to or
recoverable from any of the above by reason of injury to or death of persons, including the undersigned and
employees of CXC and loss of or damage to property of the undersigned, CXC or any third parties, arising out of or
in any manner connected with the conduct or attendance of any and all classes of instruction, seminars and
associated activity conducted by CXC, including but not limited to, firearm instruction classes.
Student Signature:_________________________________________
Date: _____/_____/______
DO NOT WRITE BELOW THIS LINE (For instructor use only)
(___) Application and Release received and filed
(___) Deposit $__________ Ck #__________ (___) Balance $____________ Ck # _______
Enrolled in: (__) Weekend (__) Week-day (__) Week-night
Dates of attendance:_________________________________________
Written Examination score: _______% Circle one: PASS FAIL WITHDREW
Range Examination score: _______% Circle one: PASS FAIL WITHDREW
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