Concealed Carry Weapon Class - University of Nebraska at Kearney

University of Nebraska at Kearney
Credit Card Information Security Form
Department Name: Nebraska Safety Center at UNK
Date: _______ / _______ / __________
Customer Name: _______________________________________
Name on Credit Card: ___________________________________
Credit Card Type: MasterCard _____
Visa _____
2014 Class Schedule
November 9, 2014
9:00 a.m. to 7:00 p.m.
On-demand classes may be scheduled with a minimum of
6 (six) students per class. For more information about ondemand class scheduling, call the Nebraska Safety Center.
Credit Card Number: ________ - ________ - _______ - _______
Expiration Date: _______ / __________
Signature as it appears on card: ___________________________
Billing Street Address: ___________________________________
Billing State: _______
Zip Code: __________
Daytime Phone: (__________) __________ - _______________
Amount to be charged: $135
“Keeping Nebraskans Safe One Day at a Time”
Reason for charge: _____________________________________
_____________________________________________________
_____________________________________________________
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(office use only)
Concealed Carry
Weapon Class
Date of entry: __________ / __________ / _______________
Processor’s Name: _____________________________________
You may register, and pay, online at: www.unk.edu/CCW
All payments must be made out to:
Nebraska Safety Center at UNK
Electronic Check Re-Presentment Policy: In the event that your check is
returned unpaid for insufficient or uncollected funds, we may re-present
your check electronically. In the ordinary course of business, your check
will not be provided to you with your bank statement, but a copy can be
retrieved by contacting your financial institution.
The University of Nebraska at Kearney is an
Affirmative Action/Equal Opportunity Institution.
Individuals needing accommodation under ADA should
contact the Nebraska Safety Center at (308) 865-8256
or the University’s ADA Coordinator at (308) 865-8655.
Nebraska Safety Center
West Center Building
UNK Campus
Kearney, NE 68849-4550
Phone: (308) 865-8755
Fax: (308) 865-8257
Toll Free: (800) 854-7867
www.unk.edu/ccw
Nebraska Safety Center
Concealed Carry Weapon Class Registration Form
***** Participant Information *****
Last Name: _______________________
Birth Date: _____ / _____ / __________
To register for this course, please complete this form by printing neatly, include payment of $135, and return to the Nebraska Safety Center.
You may register, and pay, online at: www.unk.edu/ccw
First Name: _______________________
Mailing Address: _________________________________________________________ Gender: _____________________
State: _____ ZIP: __________
Phone Number: (__________) __________ - _____________
Street Address: ___________________________________________________________
City: ____________________
Phone Number: (__________) __________ - _____________
2nd Choice: _______ / _______ / __________
Concealed Carry Weapon Class is an 8-hour course.
If you have language and/or reading difficulties, and will need accommodations, please notify the Nebraska Safety Center
office. Special arrangements can be made to accommodate those needs.
Appropriate clothing is required. Participants MUST wear shirts with sleeves, long shorts or pants, and closed-toe shoes.
Any participant who does NOT wear appropriate clothing (i.e. tank-top, mini-skirt/short shorts, flip-flops, etc.) will not be
allowed to participate in the course.
$50.00 Rescheduling Fee will be charged to any participant who does not attend.
Please note each class has a limited number of openings.
Class Date — 1st Choice: _______ / _______ / __________
E-mail: __________________________________________________________________________________________________
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Disclaimer
To release the University of Nebraska Board of Regents and their officers, agents, and employees from any and all liability, loss,
damage, claims and/or causes of action, including but not limited to all bodily injuries and property damage arising out of participation in the Concealed Carry Training course (CCW), being specifically understood that aforementioned participant may be using a
gun belonging to the participant.
The undersigned further agrees to indemnify the Nebraska Safety Center representatives and hold them harmless for any claims, judgments or settlements which may be brought or entered against them as a result of the undersigned’s participation in the Nebraska
Safety Centers CCW Training. Said indemnification shall include attorneys’ fees incurred in defending against any claim or judgment
and incurred in negotiating said settlement. It being understood that the undersigned shall have the opportunity to consent to any
such settlement, provided however, that consent shall not be unreasonably withheld.
_____ / _____ / _______
Date
Participants with any acute or chronic medical disability or under a physician’s care should not participate in this training, and participant shall
take full responsibility for any participation.
_________________________________________________
Participant Signature

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