A.  In compliance with Section 1613(a)(1) of The Corporation for the
Promotion of Rifle Practice and Firearms Safety Act, I hereby certify that:

        1.  I have not been convicted of any Federal or State felony or
violation of section 922 of title 18 United States Code, and

        2.  I am not a member of any organization that advocates the violent
overthrow of the United States Government.

B.  In consideration for being permitted to participate in any match
sponsored or supported by the Civilian Marksmanship Program (CMP) I hereby
agree to:

        1.  be bound by the CMP Competition Rules and Regulations;

        2.  waive any claim against the CMP and any organization sponsoring
or supporting the match for any personal injury, loss, or damage that I
might suffer in connection with the match, and

        3.  indemnify and hold harmless the CMP and any organization
sponsoring or supporting the match from any claim of a third party arising
from any negligent or wrongful conduct by me.

        Signed:______________________________Date:______________

        Name (please print):    __________________________
        Address:                        __________________________
                                        __________________________

__________________________________________________________________________
 

STATE OF                        )
                                        )   ss:
                                        )

BEFORE ME, the undersigned Notary Public, appeared the person making the
above certification and agreement, who under oath stated that he/she has
read, understands and agrees to it, and that the certification is true and
correct to the best of his/her knowledge.

SUBSCRIBED and SWORN TO before me, the undersigned Notary Public, on this
_____day of________________, 19___.
 
 

_____________________________
                                                Notary Public

My commission expires:_____________________