Application for New York State HR-218 Training Class

Have a photographic identification card issued by their agency.
Meets standards, if any, established by the agency which require the employee to regularly
qualify in the use of a firearm.
Have full authorization from their agency to carry and use a firearm.
Have a total of 10 or more years of law enforcement service.
Not under any disciplinary action.

Date: {{$firearm->date_1}}

First Name: {{$firearm->first_name}}

Last Name: {{$firearm->last_name}}

Address: {{$firearm->address}}

City: {{$firearm->city}}

State: {{$firearm->state}}

Zip: {{$firearm->zip}}

Cell Phone: {{$firearm->cell_phone}}

Email: {{$firearm->email}}

Agency Name: {{$firearm->agency_name}}

Active/Retired: {{$firearm->cercale_one}}

Do you carry a firearm for your agency: Circle one: Yes / No Do You have arrest Powers: Yes / No

Are you subject of any disciplinary action by the agency which could result in suspension or loss of police powers: Yes or No

How many years have you been a Peace/Police Officer: {{$firearm->date_2}}

===========================================================================

If Retired - Pistol License #: {{$firearm->Pistol_license}}

County: {{$firearm->country}}

Sign : {{$firearm->Pistol_license}}

Date Submitted : {{$firearm->date_2}}

Notes:

Qualification Course of Fire:

Fifty (50) round New York State DCJS qualification course of fire. A passing score of 70 percent with factory ammunition is required.

3-yard line – 12 rounds fired in two phases:

Phase # 1 – 6 rounds fired in two round increments – no time limit

Phase # 2 – 6 rounds fired in 6 seconds

7-yard line – 18 rounds fired in two phases:

Phase # 1 – 6 rounds fired in two round increments – no time limit

Phase # 1 – 12 rounds fired in 25 seconds with one reload

15-yard line – 12 rounds fired in 40 seconds with one reload

25-yard line – 8 rounds fired in 40 seconds with one reload

Type of Firearm Qualifying:

Gun 1 – Make: {{$firearm->gun_1}} {{$firearm->make_1}}

Model: {{$firearm->model_1}}

Score: {{$firearm->score_1}}

Gun 2 – Make: {{$firearm->gun_2}} {{$firearm->make_2}}

Model: {{$firearm->model_2}}

Score: {{$firearm->score_2}}

Gun 3 – Make: {{$firearm->gun_3}} {{$firearm->make_3}}

Model: {{$firearm->model_3}}

Score: {{$firearm->score_3}}

Gun 4 – Make: {{$firearm->gun_4}} {{$firearm->make_4}}

Model: {{$firearm->model_4}}

Score: {{$firearm->score_4}}

Instructor Validation:

Print Name: {{$firearm->print_name}}

Date : {{$firearm->validation_date}}

Signature

NYSFTA – New Student HR218 Class – “For Internal Use Only” ‐ Revision 1 – Page # 2

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