Law Enforcement Officer Safety Act
FIREARMS SAFETY COURSE INSTRUCTOR
APPLICATION FOR CERTIFICATION
In accordance with the provisions of 515 CMR 6.00 I hereby make application for certification as a Law Enforcement
Officer Safety Act Firearms Instructor.
Name ______________________________________________________________________ ____________
(Last) (First) (MI) (D.O.B.)
Residence ___________________________________________________________________ ____________
(Number and Street) (City or Town) (State) (Zip Code)
Telephone _______________________ email _____________________________________
_______________________ ________________________ ________________ ____________
LTC Number City/Town Date of Issue Expiration Date
Has your LTC or FID 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)
personal protection firearms instructor of the NRA, or other nationally
recognized organization that teaches personal protection, practical handgun skills and the proper
use of force with a firearm or a firearms instructor certified by such organization.
A federal, state or municipal law enforcement firearms instructor.
A United States military firearms instructor.
(d) A firearms instructor for the MPTC, or a firearms instructor certified by the MPTC.
(e) A Firearms instructor of a firearms
manufacturer or its academy, or a firearms instructor
certified by such academy.
(f) A Massachusetts police officer. If so, you must attach a copy of your Department issued
identification.
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 LEOSA firearms instructor by providing documentation that you are competent to give instruction in a LEOSA
Approved Firearms Course, such certification shall be at the discretion of the Colonel of the State Police.
____________________________________________________ _____________________
Signature of Applicant Date
Certification is Valid for 10 Years. Mail application and supporting documentation to:
Massachusetts State Police
Firearms Licensing
470 Worcester Road
Framingham, MA 01702
Firearms.licensing@massmail.state.ma.us
