First Name                                          

Last Name                                          

Date Of Birth                                       

Email Address                                    

Telephone Number                             

List Archery Organizations you are a member of               

*Must be a current member of or join ASA, NFAA, USAArchery at time of course registration

Membership Number                            

Expiration Date                                     

Current Certification Level                    

#Must be certified as an Intermediate Level Instructor by any organization which has a recognized Instructor Certification Program

If certification is below Intermediate Level proof that you have been working in a capacity equivalent to an Intermediate Instructor for at least one year

Date Issued                                           

Issuing organization                                

Certification Expiration Date                   

Currently Active as an Instructor (yes/no) Yes No

Member of which Club-Shop-Range       

Registering for Which Advertised Course 

By submitting this form I understand and agree  that the course fee is $250.00 and is payable in advance or at the beginning of class