APPLICATION FOR CERTIFICATION
BASIC FIREARMS SAFETY COURSE INSTRUCTOR
In accordance with the provisions of M.G.L. C.140, §131P and 515 CMR 3.00
I hereby make application for certification as a Basic Firearms Safety Course Instructor.
___________________
(Social Security #)
Name ___________________________________________________________________ ____________
(Last) (First) (MI) (D.O.B.)
Residence ________________________________________________________________ ____________
(Number and Street) (City or Town) (State) (Zip Code)
Telephone _______________________ EMAIL _____________________________________
____________________________ _____________________ ________________ ____________
License to Carry Firearms Number City/Town Date of Issuance Expiration Date
Has your License to Carry or Firearms Identification Card ever been suspended or revoked? Yes _____ No ______
If yes explain the circumstances:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Do you hold status as any of the following? (Check all that apply)
A FIREARMS INSTRUCTOR OF THE NRA, OR OTHER NATIONALLY RECOGNIZED
ORGANIZATION THAT TEACHES FIREARMS SAFETY, OR A FIREARMS INSTRUCTOR CERTIFIED
BY SUCH ORGANIZATION
A FEDERAL, STATE OR MUNICIPAL LAW ENFORCEMENT FIREARMS INSTRUCTOR
A UNITED STATES MILITARY FIREARMS INSTRUCTOR
A DIVISION OF LAW ENFORCEMENT BASIC HUNTER EDUCATION INSTRUCTOR
A FIREARMS INSTRUCTOR FOR THE CRIMINAL JUSTICE TRAINING COUNCIL, OR A FIREARMS
INSTRUCTOR CERTIFIED BY THE CJTC
A FIREARMS INSTRUCTOR OF A FIREARMS MANUFACTURER OR ITS ACADEMY, OR A
FIREARMS INSTRUCTOR CERTIFIED BY SUCH ACADEMY
If you have answered yes to any of the above categories you must attach a copy of your certificate of completion with
your application.
If you do not hold status in any of the above categories, you still may receive certification as a basic firearms safety course
instructor by providing documentation that you are competent to give instruction in a Basic Firearms Safety Course, which
may include any person who operates a firearms safety course or program as described in G.L. c. 140, § 131P(b), such
certification shall be at the discretion of the Colonel of the State Police.
____________________________________________________ _____________________
Signature of Applicant Date
Application must be accompanied by a fee of $50.00. Mail application and supporting documentation to:
Make check or money order payable to:
Massachusetts State Police
The Commonwealth of Massachusetts Firearms Licensing
470 Worcester Road
Certification is Valid for 10 Years Framingham, MA 01702
(508)-988-7434
