LEOSA Registration Form

LEOSA (HR-218) Registration
Photo for ID card (shoulders up)
Your Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Active or Retired?
Were you a Police Officer?
Were you a Peace Officer?
What agency did you retire from?
What was your title/rank?
Copy of your Department ID Card?
ALL LEGAL FIREARMS
Make
Model
Serial #
If you have any additional firearms that you will be qualifying with, please list MAKE, MODEL, & SERIAL NUMBER for EACH additional firearm below.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address to Send ID to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notice: Each aspect of the NYS DCJS Course of fire, time, proficiency, safety, and handling of the firearm must be passed. Failure to meet NYS standard will result in no ID card being issued and no refund of your registration fee.
For questions, contact Elinor Hood at 607-746-2258 ext. 106 or hood.elinor@villageofdelhiny.gov
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LEOSA (HR-218) Registration