Michael R. Grimler's New Mexico Concealed Carry Class Student Information Sheet
This information is required by the New Mexico Department of Public Safety in accordance with the New Mexico Concealed Handgun Carry Act. This record must be maintained by me for a period of three (3) years.

This is a secure form and data will be encrypted when you hit the "Submit" button. Your sensitive information is safe.

The fields marked with a red asterisk are required fields.

Please contact me at mgrimler@wyor.com if you have any questions, thanks.

Michael R. Grimler
NM CCW DPS Instructor #21

Email address *
Today's Date *
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Class Start Date *
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Which kind of class are you signing up for? *
First Name *
Your answer
Middle Initial or Name
Your answer
Last Name *
Your answer
Date of Birth - PLEASE ENSURE PROPER YEAR! *
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Mailing Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Firearm Information
Enter the firearm(s) (up to two) with which you want to qualify and have shown on your New Mexico CCW permit.

If you are RENEWING your NM CCW permit - and, you want your renewed permit to have the same firearms listed, you MUST qualify with the category and caliber listed on your current license.

NM DPS recognizes two "categories" of firearms; Semi-Automatics, and Non-Semi Automatics. The Non-Semi Automatics category covers firearms such as revolvers and derringers.

If you want a semi-automatic and a revolver on your license, you must shoot the qualification course with a firearm of each category

It is advisable to shoot the largest caliber of each category with which you wish to qualify. You will then be able to carry concealed any firearm that matches the caliber qualified with, and any smaller caliber within that category.

CAUTION: If you have a revolver that shoots a .45 caliber bullet, as well as the .410 shotgun shell (e.g., the Taurus "Judge"), you should know that NM DPS does not allow the .410 shell carried in the firearm while concealed.

NOTE: If you have a magnum firearm, such as a .44 magnum, or a .357 magnum...you can shoot the "specials" within that category for qualification - you do not have to shoot the magnum rounds.

Firearm #1 *
Firearm #1 Caliber *
Firearm #2 *
Firearm #2 Caliber *
Affirmation and Agreement
I do hereby affirm that the information I have entered above is true and correct. I understand that when I hit the "SUBMIT" button below for this form that it is the same as if I had signed my name in person and carries the full legal weight of a personal signature.

I understand that these NM CCW classes are designed for shooters of at least an INTERMEDIATE skill level. As such, I affirm that I am familiar with drawing my firearm safely from a holster, safely re-holstering, the fundamentals of marksmanship to include sight picture, sight alignment, stance, grip, trigger pull, and I am familiar with the proper and safe loading and reloading of my firearm.

I further understand that I may be asked to leave the class, if directed by the instructor, for any firearm safety violations observed or reported. If I am asked to leave the class for such safety violations, I may forfeit all or part of my paid class fee. I acknowledge that Michael R. Grimler, Firearm Instructor reserves the right to refuse instruction to anyone before the class starts. If I am refused instruction, I am entitled to a full refund of any class fee paid to date before the class.

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