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Last Name
First Name
MI
Preferred Name(for name tag/tent)
Officer/Deputy Corporal Detective Sergeant Lieutenant Captain Major Deputy Chief/Chief Deputy Assistant Chief Chief Sheriff Tele-Communicator Telecommunications Manager Retired Other Rank if other:
Title
PID#
Date Of Birth
() - Participant Phone
Participant Email
Gender: Female Male
Please inform us of any food allergies:
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
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
#FT Officers in Department
If no notice of cancellation is received by the Program Coordinator prior to the date of the program, and the participant does not attend the program, the participant or their agency will be required to pay a $100 'NO-SHOW' fee.
I have read and agree to the above policies.