Last Name

First Name

MI

Preferred Name
(for name tag/tent)

Officer/Deputy Corporal Detective Sergeant Lieutenant Captain Major Deputy Chief/Chief Deputy Chief/Sheriff Other
Rank
      if other:

Title

PID#

Date Of Birth

() -
Participant Phone

Participant Email

Years of Service

Gender:     Female     Male

Please inform us of any food allergies:

Responsibility:
    Chief Executive Officer
    Commander / CEO
    Mid. Management
    Operations Level
    First Line Supervisor

Education:
    Less than AA or 60 hours
    AA or over 60 hours
    Bachelor's degree
    Master's degree
    Terminal degree

Ethnicity:
    Black
    Indian
    Hispanic
    Asian
    White / Anglo

Supervisor's Full Name

Supervisor's Email

() -
Supervisor's Phone

Agency / Department

() -
Agency Phone

Agency Email

Mailing Address

City

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
State

Zip

County

Precinct

#FT Officers in Department

Course is $395 per person. One participant per agency per class.

I will be paying by:

    Online by Credit Card or Electronic Check
    Paper Check/Purchase Order  (Check/PO # )

You will be contacted with payment information
once the minimum number of attendees has been reached.

If the participant has already paid, he/she will be refunded half the cost of the registration fee if written notice of cancellation is received by the Program Coordinator no later than seven (7) business days prior to the program. No refunds are available after this date, but substitutions of attendees are permitted.

If no written cancellation is received and the participant does not attend the program, the participant or their agency will be required to pay 100% of the registration fee if the registration fee was not previously paid.

I have read and agree to the above policies.