Houston Police Department

Qualification Form for Retired Officers Qualifying at other Department Ranges

Federal Qualification State Qualification State CHL Qualification Date: ______

Retired Officer’s Name ______Payroll #______

Social Security Number______

Weapon #1 _____ Semi-automatic _____ Revolver Passed Failed

Make ______Serial number ______Caliber ______

Weapon #2 _____ Semi-automatic _____ Revolver Passed Failed

Make ______Serial number ______Caliber ______

I, range Officer (print)______of the______Department certify that the above retired Officer has met or exceeded the below qualification course.

______

Range Officer Signature Range Phone Number

I have met or exceeded the Houston Police Department revised retiree qualification course, circular # 07-0117-010, signed by Chief H. L. Hurtt. This includes that:

Initial

______I have completed annual demonstration of firearm care, cleaning and an external inspection by the range officer to verify the safety and function of the weapon(s) and a course of fire consisting of fifty (50) rounds. the minimum qualification score for the revised course is 75%. The course is as follows:

Hip shooting 15 rounds at 2yds no time limit, one 30 second timed reload Two handed 30 rounds at 7 yards no time limit Two handed 5 rounds at 15 yards no time limit

______Applicant’s Signature