Course Enrollment Application Student Information Full Name: ________________________________________________________ Male/ Female: ______ Military Unit or LE Affiliation (if applicable): ______________________________ Rank: ___________ Mailing Address: ______________________________________________________________________ City: ____________________________ State: ______________________ Zip Code: _______________ Home Phone: _____________________ Work Phone: ________________ E-Mail: _________________ Country of Birth: ___________________ Country of Citizenship (List All): _______________________ Emergency Contact Person: __________________________________ Phone: _____________________ Training Requested Course Name: _______________________________________ Date: _____________ Cost: __________ Course Name: _______________________________________ Date: _____________ Cost: __________ Weapon Information (if bringing your own) Primary Weapon: ___________________________ Caliber: __________________________ Secondary Weapon: _________________________ Caliber: __________________________ If Civilian: Primary Weapon License No.: ____________________ State of Issue: _________ Exp. Date: _________ Secondary Weapon License No.: __________________ State of Issue: _________ Exp. Date: _________ Credential Policy Redback One, LLC has a strict credential policy. A photocopy of one of the following must accompany your application. A Valid State Issued Driver’s License is required for all driving courses. Military and Law Enforcement - Valid Active Duty Military ID - Valid Active Duty Agency ID Civilian - Pistol License (any state) and Valid State Issued Driver’s License
P.O. Box 15327, Chesapeake, VA 23328-5327
www.redbackone.com
(757) 318-1024 or (757) 839-8375
Rental Support (Optional) Please specify your rental requirements below: Weapons Each weapon includes 3 magazines and a cleaning kit. The M4 includes a sling. Cost: $30 per day per weapon. ☐ Glock 17
☐ M4 Carbine
Gear Cost: $5 per day per item; excludes the armor carrier. Holster: ☐ Right handed ☐ Left handed ☐ Pistol magazine carrier ☐ Duty belt
Size: _______
Cost: $10 per day ☐ Armor carrier (Includes mag pouches) Ammunition Purchase (Optional) Ammo will be sold in 1000 round cases. Caliber: __________ Number of rounds: __________ Caliber: __________ Number of rounds: __________ Application Submission & Payment Options (Full payment due with submission of application) Please mail your application along with payment to: Redback One, LLC ATTN: Sales P.O. Box 15327 Chesapeake, VA 23328-5327 Check Enclosed ☐ Credit Card: ☐VISA
☐MasterCard
☐Discover
Account No.: ________________________________________ Exp. Date: _________ CVV: _________ Name as it appears on card: ______________________________________________________________ Billing Address: _______________________________________________________________________ City: ____________________________________ State: ____________________ Zip Code:__________ Signature of Cardholder: ________________________________________________________________ P.O. Box 15327, Chesapeake, VA 23328-5327
www.redbackone.com
(757) 318-1024 or (757) 839-8375
Or Submit your application via email to
[email protected] and pay via Credit Card by Phone Call (757) 318-1024 to make a payment via the following:
Refund and Cancellation Policy If Redback One, LLC cancels a scheduled course, full tuition is refundable or can be applied toward another course. Cancellation made 30 days or more prior to a scheduled course, a full refund will be issued. Cancellation 2 weeks prior to the first day of a scheduled course, half tuition is refundable or full tuition can be applied toward another course. Cancellation with less than 2 weeks prior to a scheduled course, tuition is NON-REFUNDABLE or half tuition can be applied toward another course. Failure to appear and drop from training, tuition is NON-REFUNDABLE. Attending or completing a course, tuition is NON-REFUNDABLE. Be sure of your own schedule before submitting an application. Agreement I wish to apply for enrollment in the course indicated above. By signing this application, I am acknowledging that I understand and agree to the following: 1. I will be at least 18 years of age at the time of training and have no history involving conviction of any crime which constitutes a felony or a misdemeanor of any kind, or a summary offense involving force, threats or physical violence. 2. My enclosed credentials meet the requirements outlined by Redback One, LLC and I must positively identify myself as the same person certified on the class roster accompanying this application upon arrival for training. 3. I am a citizen of the country(ies) listed above. 4. Redback One, LLC depends upon the careful control of firearms by each student. I will abide by any and all safety procedures required by Redback One, LLC and agree to complete, sign and understand REDBACK ONE, LLC’s LIABILITY WAIVER AND ASSUMPTION OF RISK in which, I will acknowledge that I have assumed all risks attendant upon participation in a course involving firearms, the P.O. Box 15327, Chesapeake, VA 23328-5327
www.redbackone.com
(757) 318-1024 or (757) 839-8375
use of live ammunition and/or tactics. I understand that by signing the waiver I will release the course staff and the host facility from any liability for injuries I may sustain or cause during my training. 5. I understand my instruction may be terminated at any time during the class if the staff deems my cooperation and behavior unsatisfactory. There will be NO REFUND. 6. Instruction given by Redback One, LLC is for the sole purpose of instruction for the students attending the course ONLY. We assume no liability for any student attending a course who uses any information obtained in the course to instruct others. ______________________________________ PRINT NAME ______________________________________ APPLICANT’S SIGNATURE
P.O. Box 15327, Chesapeake, VA 23328-5327
_______________________ DATE
www.redbackone.com
(757) 318-1024 or (757) 839-8375
