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Mark L. Goodman
Christopher Lyons
Lou Gold
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Application Form
Application Form
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2016-05-20T13:19:59+00:00
Proactive Self Defense Application Form
Step 1 of 3
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Your Email
*
Emergency Contact
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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?
By a friend
By a gun store
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
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
Expiration Date
Security Code
Cardholder Name