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Last Name ______________________________
First Name _______________________ Initial ______
Agency/Dept.
_________________________________________________________________
Department Address
____________________________________________________________
City
__________________________________ State ____________________ Zip ___________
Phone
__________________________________
Student Address:
Street
__________________________________________________________________
City
_________________________________ State ____________________ Zip ____________
Phone
_____________________________________ email address
_________________________
Name Make Model and Caliber of
Defensive Weapon you will be bringing to the course. (rentals available)
Training Course Number
____________ Date ____________________ Cost ______________________
Training Course Number
____________ Date ____________________ Cost ______________________
Training Course Number
____________ Date ____________________ Cost ______________________
Mail payment with application. You
will receive course confirmation by mail with location map.
Vermont Tactical C/O Gary LeRoux
224 Oberland Valley Road
Montgomery Center, Vermont 05471
1-802-326-5003 WWW.VTTAC.COM
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