Application Form

33%

Plan One - Monthly
Price: $13.95
Plan Two - Monthly
Price: $18.95
Plan Three - Monthly
Price: $34.95
Plan One - Yearly
Price: $119.00
Plan Two - Yearly
Price: $169.00
Plan Three - Yearly
Price: $299.00
Application Processing Fee
Price: $12.00
One time charge only and does not repeat every month / year. 100% of this will be donated to the Connecticut Citizens Defense League (CCDL).
Total
$0.00
Name*
First Last
Date of Birth*
Home Phone*
Cell Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Your Email*

Which of the following do you possess?*
- A valid CT pistol permit
- A valid eligibility certificate
- A valid long gun eligibility certificate
- A legal firearm
How were you referred to us?
Friend / Gun Store Name
By clicking below, I agree to the following*
- Agree
- I have accepted to the terms and conditions and notice of privacy of Proactive Self Defense LLC
- I am at least 21 years old and can legally own a firearm(s) in the State of Connecticut.
Credit Card Details*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Emergency Contact