Court Required Pistol Safety Training class

Your instrucor- Gerald A. Wrage - learn more here

All Information provide to us on this form is held in strick confidence and not released to anyone with out the written approval of the provider. Please contact us at 248-309-9579 if you any questions about the use of this form.

1. Client Personal Information

First Name

Last Name

Street Address

City

Zip Code

Phone Number

Email Address

Your age

2. Incident Information Request Section

Instructions: Please complete incident request form to the best of your knowledge. If you do not know the answer or do not have access to the information leave the answer to the question blank. If necessary I will get back to you regarding questions.

Note: all information collected on this form is strictly confidental

What was offense where you charged with?

What is your probation plea agreement charge? ( If different than above)

What is the duration of your probation? How many months?

Training completion date: (By what date do you have to complete this training )? +

Incident Summary - Please give a brief description of the incident

was a firearm or other weapon used in the incident. If yes, what kind?

Time of Incident ( note am or pm)

Incident Date +

Incident Location

Case Number

Responding Police Dept.

County Jurisdiction

Were you arrested?

Yes

Pobation Officer

Probation Officer First Name

Probation Officer Last Name

Probation officer Phone Number

Probation Officer Email Address

District Court

Probation Training Payment Section

Probation Training Fee. $ 300.00 Fee is processed through PayPal. Will accept a credit card or PayPal account. Your payment will show a fee paid to Protect Systems. Our state and federal registered business name.

Payment Options

Option One: Check box below and pay complete fee of $300.00 here

300.00

Option Two: the 50/50 split. Pay $150.00 now and $150.00 at end of class. check box below to make the initial $150.00 payment.

150.00

If you prefere another payment option please contiue to submit information and contact us at 248-309-9579

Check your total here before proceeding.

$0.00

Document Attachment location- If possible, please attach any supporting documents that provide us with usful information regarding your case. These usually include police reports etc. Document will have to be on your computer in Microsoft word or PDF fromat.

Our contact information

Office Location

556 Tennyson, Rochester Hills, Mi 48307

Phone and text 248-309-9579

E mail: protectsystems@sbcglobal.net

Instructor - Gerald A. Wrage

Training Center 1681 E. Auburn Rd. Ste F

Avalaible by appointment only.