DELAWARE RIFLE & PISTOL CLUB, INC.

P.O. BOX 6107

WILMINGTON, DELAWARE, 19804

www.drpclub.org

302 995-9956

PLEASE TYPE OR PRINT CLEARLY

Type required info. into the fields provided then print the application and mail

to the P.O. Box provided above along with the DRPC Pistol Training Course fee.

Date: Click here to enter a date.

Last Name: Click here to enter text. First: Click here to enter text. MI:

Street Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip: Click here

Date of Birth: Click here to enter text.

Home Phone: Click here to enter text.

Mobile Phone: Click here to enter text.

E-mail: Click here to enter text.

NRA Membership # Click here to enter text. Expiration:

Delaware State Sportsmen’s Association Member # Click here to enter text. Expiration:

Driver’s License: State Choose an item. Number Click here

Occupation & Employment: Click here to enter text.

Skills you can volunteer to help club: Click here to enter text.

Shooting Experience (briefly describe): Click here to enter text.

Firearms Safety Courses Completed (list): Click here to enter text.

Certifications (e.g., Instructor, Coach): Click here to enter text.

Are you (check all that apply): ☐ A Veteran; ☐ Active-Duty Military; ☐ Law Enforcement;

☐ First Responder; ☐ Physician/PA; ☐ Nurse/NP; ☐ Medical Professional

Certification for Membership

Please answer the following questions “yes” or “no” 1. Are you under indictment or information in any court for a felony, or any other crime, for which a judge could imprison you for more than one year? (An information is a formal accusation by a prosecutor.) Choose an item.
2. Have you been convicted in any court of a felony, or any other crime, for which the judge could have imprisoned you for more than one year, even if you received a shorter sentence including probation? Choose an item.
3. Are you a fugitive from justice? Choose an item.
4. Are you an unlawful user of, or addicted to, marijuana, or any depressant, stimulant, or narcotic drug, or any other controlled substance? Choose an item.
5. Have you ever been adjudicated mentally defective or have you been committed to a mental institution? Choose an item.
6. Have you been discharged from the Armed Forces under dishonorable conditions? Choose an item.
7. Are you subject to a court order restraining you from harassing, stalking, or threatening an intimate partner or child of such partner? Choose an item.
8. Have you been convicted in any court of a misdemeanor crime of domestic violence? Choose an item.
9. Have you ever renounced your United States citizenship? Choose an item.
10. Are you an alien illegally in the United States? Choose an item.
11. Are you a citizen or legal permanent resident (hold a Green Card) of the United States? Choose an item. Note: Non-immigrant aliens are not eligible for membership in Delaware Rifle and Pistol Club.

I Kenneth W. McQueston , certify that the above answers are true and correct. I understand that answering falsely will result in rejection of this application or termination of membership if such falsification is discovered after completing the membership process. I understand that a person who answers “yes” to any question 1 through 10 is prohibited from purchasing, receiving, or owning a firearm, and is therefore not eligible for membership in the Delaware Rifle and Pistol Club. Further, by signing this application, I am authorizing the Board of Directors of the Delaware Rifle and Pistol Club to conduct a background check on me as they deem necessary.

SIGNATURE: _______________________________DATE: Click here to enter a date.

YOU MUST COMPLETE AND SIGN THE “CERTIFICATION FOR MEMBERSHIP” OR YOUR APPLICATION WILL NOT BE ACCEPTED.

THIS SECTION TO BE COMPLETED BY CLUB OFFICER ACCEPTING THE FORM

New Member Orientation Fee Received: ☐ Yes ☐ No

Date Paid:

Amount Paid (Check/Cash/MO):

Check Number:

Date:

Qualification Checklist:

☐ Membership Dues Paid (Pro-Rated)

☐ NRA Member Number Verified

☐ DSSA Member Number Verified

☐ Legal Waiver Form Received (Junior Members Only)

☐ Key Issued, Key Number _________

Membership Status: ☐ Active ☐ Spousal ☐ Junior