Course Restrictions:  Each Prospective student is required to read this form in it's entirety.  If the student can truthfully answer "Yes" to each of the below numbered categories, then sign this form in the presence of a valid Notary Public.  This original form must be completed and returned with the Enrollment for and course fee attendance and participation.

1. I am 23 years old and I have lived in the state for at least 6 months or more, or I am a member (or spouse of a member) if the armed forces stationed in Missouri.
2. I am not a fugitive from justice, and I am not currently charged with any crime that involves an explosive weapon, firearm silencer, or gas gun.
3. I have not been convicted of a felon in this or any other state, I have not received a Dishonorable Discharge from the U.S. Armed Forces, and I have not been convicted or plead guilty to a charge of Domestic Violence.
4. I have not been convicted of, pled guilty to, or entered a plea of "no contest" to one or more misdemeanor offenses involving crimes of violence within a 5 year period immediately preceding my registration for the Mineral Area College Firearms Safety Training Course.
5. Within the last 5 years, I have not been convicted of two or more DWI's or drug possession/abuse charges.
6. I have not engaged in a pattern of behavior, documented in public records, that would cause the sheriff to have reasonable belief that I present a danger to myself or others. 
7. I have not been adjudged mentally incompetent at the time of this registration, and I have not been committed to any mental health facility or similar institution within the last 5 years, and I am not named as the respondent in a valid full order of protection which is still in effect.

My responses above are true and correct to the best of my knowledge.  I understand that if I knowingly provide false, incomplete or misleading information concerning this eligibility affirmation, I will be reported to the proper legal authorities for criminal and/or civil prosecution to the fullest extent of the law.

Print Full Name of Student:_____________________________________________________

Student Signature:__ ____________________________________Date:__________________

FOR COMPLETION BY A NOTARY OF PUBLIC:

Subscribe and sworn to before me this ________day of _____________________, 20_____.

I am commissioned as a notary public within the county of ____________________________, state of _______________, and my commission expires on _____________________, 20_____.

                                                                                                                             ____________________________

                                                                                                                             NOTARY PUBLIC

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No use authorized without permission of the Director of MACLEA.