Page I GEORGIA BOARD OF PRIVATE DETECTIVE AND SECURITY 237 COLISEUM DRIVE MACON, GA. 31217 WEAPONS DISCHARGE REPORT FORM Please Note: All infomation must be provided. ?5 Name; License Number: Permit: Concealed: 5 Name: Co. License Number: 5 Address: State: Su 3 Name: Phone Number: Date of Discha 9 Time of Discha Time Noti?ed: Noti?ed: Location: Street: Give exact location including city where weapon was discharged: of Wea Give a detailed account of the circumstances 5 the d? of wea . Use additional as needed. Please attach in-house with witness statements. Were the noti?ed? If inciude urisdiction and case number of incident Were there an ries from the wee discha Yes If in: Name of! ured Address of Pa Page 2 DISCIPLINAR ACT ION FIRING RANGE SCORES AND Was disciplinary action taken23:99:39: 1" i Submit certi?cation of most recent firing range scores: Date: Score: Firearms Instruction: Date; 3 .947: zoo 9 (re-trainng is required) Firearanstructor: ?77277077! 5? 455% out . firearm Instructor's Si natur . NOT me. a mad ?v0 I certify and declare that the above information is true and correct. er decinre that I have recounted the weapons discharge incident to the best of my knowledge. Date of Report: ?1 Employee Signature: arm Supervisor's Signature: Sworn?ysubo?dbed to before me this ?on? Attachments: Company Report Witness Statements Police Repon (if noti?ed) New Range Scores Training Certi?cation NOTARY Do Not Write in this Section: Board Of?ce Use Only: Presented to Board: Action Taken: -- .. I - 7 Tat_Lx{lj?f?gl'g . *wm?k? -. . a -