Black Badge Candidate

Have you successfully completed the CSSA Club Level Safety Course?

Yes    No   

Have you completed any other firearms related training courses, and if so please list them:

Do you have any physical condition that may adversely affect your performance on this course?

Yes    No   

If yes, explain briefly:

Firearm you intend to use for this course:

Make:

Model:

Caliber:

Please list any modifications to this firearm:

Approximately how many rounds have you fired from this firearm?

100 to 499    500 to 1000    >1000   

Are the controls, (safety and mag release), easily manipulated with the strong hand only?

Yes    No   

How many magazines or speedloaders do you have for this firearm?

2    3    4    More than 4   

Do you reload for this firearm?

Yes    No   

Is your firearm reliable with this ammo?

Yes    No   

If not, are you prepared to obtain and have on hand at least 500 rounds for this course?

Yes    No   

Holster for the course: (Please note that button activated holsters are not allowed.)

Make:

Model:

Left Handed?

Yes    No   

Duty Rig?

Yes    No   

Do you have sufficient magazine pouches or speedloader holders and a belt to carry them on?

Yes    No   

Can you make th eaccuracy prerequisite of 9 out of 10 shots on a 30cm x 30cm target at 20m?

Yes    No   

Have you ever been denied access to, rejected from, or failed to complete any other Black Badge Training Program or other firearms safety course?

Yes    No   

If yes, please explain: