NOTE: Successful completion of an NRA Training Counselor Workshop is one requirement for training counselor appointment. Candidates are evaluated on a variety of criteria, including experience in conducting NRA basic courses, shooting, teaching, leadership, community service, and references' recommendations.

I wish to attend the workshop being held in: ________________________ (city/state) on: ________________________ (dates)

Name ___________________________________________________________

Instructor/TC ID number ______________________ Exp. Date _______

Street Address ___________________________________________________

City, State, Zip _________________________________________________

Daytime Phone ________________ Evening Phone _________________

E-mail Address: _______________________________________________

I am currently a:

____	NRA Training Counselor
____	NRA Certified Instructor

Instructor ratings held:

____ Rifle ____ Shotgun ____ Personal Protection ____ Muzzleloading Pistol ____ Reloading Metallic ____ Range Safety Officer (non-instructor course)

____ Pistol ____ Home Firearm Safety ____ Muzzleloading Rifle ____ Muzzleloading Shotgun ____ Reloading Shotshell ____ Chief Range Safety Officer

Number of NRA Basic Firearm Training Courses held/students trained during the past two years:

(Example: Two rifle courses with a total of 17 students would be "Rifle 2/17")

Rifle _____/_____ Shotgun _____/_____ Personal Protection _____/_____ Muzzleloading Pistol _____/_____ FIRST STEPS Pistol _____/_____ FIRST STEPS Shotgun _____/_____

Pistol _____/_____ Home Firearm Safety _____/_____ Muzzleloading Rifle _____/_____ Muzzleloading Shotgun _____/_____ FIRST STEPS Rifle _____/_____ Reloading _____/_____

Were you the chief instructor for any of the above courses? _____

If yes, how many? _____

Date of last NRA Basic Firearm Training Course you taught: _____________

Number of NRA Instructor Training Courses held/instructors trained during the past two years:

Rifle _____/_____ Shotgun _____/_____ Personal Protection _____/_____ Muzzleloading Pistol _____/_____ Reloading Metallic _____/_____ Range Safety Officer (non-instructor course) _____/_____

Pistol _____/_____ Home Firearm Safety _____/_____ Muzzleloading Rifle _____/_____ Muzzleloading Shotgun _____/_____ Reloading Shotshell _____/_____

Were you the chief training counselor for any of the above courses? _____

If yes, how many? _____

Date of last NRA Instructor Training Course you taught: _____________