MEMBERSHIP APPLICATION

Diasporans Firearms Club
Phone: (516) 777-0263
Email: admin@diasporansfc.org
Website: www.diasporansfc.org
MEMBERSHIP APPLICATION
Type a question
Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
County

Other
Employer:
Business Address:
Occupation:
Phone:
Format: (000) 000-0000.
Do you have any LEO/Military experience?
Explain:
Have You Ever Been Arrested:
Charge(s):
Convicted of:
Disposition:
Have you ever been treated for Mental Illness:
Do you certify that you do not have a Restraining Order or Protective Order issued against me?
Do you certify that you have never been convicted of a felony?
Do you certify that you are not an unlawful user or distributor of any illegal drugs?
Do you certify that you have not been dishonorably discharged from any branch of the US Armed Forces?
Handgun Permit No.:
Expiration Date:
Who referred you to the DFC?
I Have Downloaded, Read & Agree To: DFC's Code of Conduct, Range & Firearms Safety Rules, and Waiver & Release Agreement.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you interested in meeting with the 2A attorney:
NAAGA ID:

Single Annual Membership

$125.00 Quantity

Couple Annual Membership

$200.00 Quantity

Family Annual Membership

Family of up to four living at the same address

$250.00 Quantity

Total