<p> Qualification Form for Retired Officers Qualifying at other Department Ranges</p><p>Federal Qualification State Qualification State CHL Qualification Date: ______</p><p>Retired Officer’s Name ______Payroll #______</p><p>Social Security Number______</p><p>Weapon #1 _____ Semi-automatic _____ Revolver Passed Failed</p><p>Make ______Serial number ______Caliber ______</p><p>Weapon #2 _____ Semi-automatic _____ Revolver Passed Failed</p><p>Make ______Serial number ______Caliber ______</p><p>I, range Officer (print)______of the______Department certify that the above retired Officer has met or exceeded the below qualification course.</p><p>______</p><p>Range Officer Signature Range Phone Number</p><p>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:</p><p>Initial</p><p>______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:</p><p>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</p><p>______Applicant’s Signature</p>