New Application

FORM A (NEW APPLICATION)

As a new applicant to IROCC, this form will need to be completed in full, printed, signed by participant and participant's HR representative, Chief, or Deputy Chief and mailed to IROCC along with any requested documentation and a check or money order.

Personal Info

First Name

Middle Initial

Maiden Name

Last Name

Date of Birth

Gender

FOID Card Number

Address

Legal Residence

City

State

Zip Code

County

Contact

Email Address

Primary Phone

Secondary Phone

Firearm Type(s) You Intend to Qualify With

revolver
Semi-Automatic

Retirement Details

Agencies You Retired/Seperated From

Start Date

End Date

Agencies You Retired/Seperated From

Start Date

End Date

Agencies You Retired/Seperated From

Start Date

End Date

Please confirm before advancing

I Confirm that I Am Applying for an IROCC Certification and am of sound body and mind