Registration

Member Information

Name*

First Last

Date of Birth*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home Phone*

Cell Phone

Work Phone

Membership Type

Membership*

Additional Employees

Price: $185.00

For Family Memberships, please list the full names of all family members and the ages of any children included:

e.g. Jeff Sanders 10 years old

Bonus Shot: Pay $100 more for your Membership and receive free gun rental for the year!*

Yes
No thank you

Total

$0.00

Emergency Contact Information

Name (Emergency Contact 1)*

First Last

Phone (Emergency Contact 1)*

Relation to Emergency Contact 1

Name (Emergency Contact 2)

First Last

Phone (Emergency Contact 2)

Relation to Emergency Contact 2

Name (Emergency Contact 3)

First Last

Phone (Emergency Contact 3)

Relation to Emergency Contact 3

Do you have known allergies?*

Yes
No

If yes, please describe:

Driver's License and F.O.I.D Information

Driver's License Number*

Driver's License State*

e.g. IL

Driver's License Expiration*

F.O.I.D Number*

State*

e.g. IL

F.O.I.D Expiration Date*

How did you hear about us?*

Payment Information

Total

$0.00

Credit Card*

American Express

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MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Attestation

I do hereby attest that the information I have provided in this form is true and correct. I further assert that I am not prohibited by law from possessing or handling firearms. If it is found that any information provided by me is false, I understand that my membership with On Target Range and Tactical Training Center will be terminated immediately, with no refunds.

I agree to the above statement

Applicant Signature*

First Last

Date Signed*

Member Information

Membership Type

Emergency Contact Information

Driver's License and F.O.I.D Information

Payment Information

Attestation

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