LEOSA 4 January 2025 Saturday

LEOSA Requal Saturday, 4 January 2025, 0900, Shoot Straight Tampa

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

I have a Glock 44 .22 Semi-automatic and holster if you need to borrow a firearm ($10.00 additional fee)*

Yes, please, and I'll bring .22 ammo or buy it at the range.No, thanks, I'll bring my own gear.

5-Shot Revolvers are no longer acceptable for the new LEOSA Course. If you want to qualify with a revolver bring your own 6-shot revolver or I can bring one for you.

I have a 6-shot 38 Revolver and holster if you need to borrow a firearm (10.00 additional fee)*

Yes please, and I'll bring .38 ammo or buy it at the range.No thanks, I'll bring my own gear.

Due to the amount of time required to fire the new course we may not be able to accomodate your 2nd firearm type (Semi-Auto or Revolver). Please be ready to fire the type you prefer.

I will be firing:*

Semi-Automatic onlyRevolver onlyBoth

What Agency did you retire from? *

YOU MAY PAY NOW OR AT YOUR SESSION! If you pay at the session do not click any of these boxes...go directly to the Signature and Submit button.

LEOSA RequalMake sure to select the box to the left

$55.00

Glock .22 Semi-Auto Rental (includes holster) Ammo available at the range. Product Image

Glock .22 Semi-Auto Rental (includes holster) Ammo available at the range.Make sure to select the box to the left

$10.00

38 Revolver Rental (includes holster) Ammo available at the range. Product Image

38 Revolver Rental (includes holster) Ammo available at the range.Make sure to select the box to the left

$10.00 Quantity

Total

$0.00

Credit Card

It is expressly agreed that all use of the equipment and facilities of Ex Umbra Defense Solutions are undertaken at the sole risk of the undersigned. Undersigned agrees to hold harmless, release, and forever discharge Ex Umbra Defense Solutions, their operators, agents, employees, consultants, advisors, owners, and leasers of its equipment from all claims for injury, death, or damage to the undersigned's person or property arising out of or in conjunction with the use of the premises or equipment, or passive negligence on the part of Ex Umbra Defense Solutions.

By signing this waiver, I confirm that I may lawfully possess a firearm in the State of Florida. I am not a convicted felon, nor am I currently under any criminal charges for any felony, violent misdemeanor, or domestic violence. I am not subject to any domestic violence injunctions. I am not currently under the influence of alcohol, illegal substances, or medications that would impair my ability to safely handle a firearm. I am not aware of any other reason that would prohibit me from lawfully possessing a firearm.

By typing my name below, I acknowledge and agree that my electronic signature is the legal equivalent of my manual/handwritten signature. I consent to be legally bound by the terms and conditions of this document.

I understand that by entering my name, I am agreeing to the provisions outlined in this document as if I had signed it in writing.

Please enter your legal name*

Range

Firearm Type

Score

Card Number