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American Medical Resource Institute

AMERICAN MEDICAL RESOURCE INSTITUTE ILLINOIS CONCEALED CARRY COURSE APPLICATION

PRINT OR TYPE

COURSE DATES ENROLLING FOR:_________________________________


FIRST NAME______________________________ LAST NAME_______________________________MIDDLE INITIAL_____________


MAILING ADDRESS___________________________________________________________________________________________


CITY__________________________ STATE_____ ZIP___________________ DAY PHONE (______)__________________________


ILLINOIS FOID NUMBER *_____________________________________________EXPIRATION DATE__________________________


EMAIL ADDRESS: [email protected]_______________________________________


YOUR AGE _____________ SEX ______________ DO YOU HAVE ANY PHYSICAL LIMITATIONS? YES____ NO____

TUITION: $2 95 (full 16-hour course) $1 95 (8-hour course) $85 (4-hour recertification course)

CHECKS PAYABLE TO: AMERICAN MEDICAL RESOURCE INSTITUTE

If you would like to pay by credit card, call us at: 1-800-272-9064 (Monday - Friday 9am-5pm)

* FOID is not required if you are not an Illinois resident. If you are an Illinois resident waiting for the State to send your FOID card, you may take the course, however, you will need to have your current FOID card to submit your Illinois State Police concealed carry license application.

YOU CAN PRINT THIS APPLICATION AND MAIL TO:       FOR CREDIT CARDS: CIRCLE TYPE (MC VISA AMEX DISCOVER)

AMERICAN MEDICAL RESOURCE INSTITUTE

2-B Public Safety

715 Ela Road

Lake Zurich, IL 60047-6300


FAX: 1-888-833-2674


scan/email: [email protected]


NAME ON CARD_____________________________________________



CARD NUMBER_____________________________________________



EXPIRATION ______/_________ SECURITY CODE ________________

YOUR SIGNATURE___________________________________________ AMOUNT CHARGED $________________________

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