APPLICANT * REQUIRED First Name * Last Name * Position/Title/Rank * Phone Work: * Mobile Phone: Attendees Agency Email Address: * no personal email address (DO NOT USE ALL CAPS) Retype your e-mail address: * FOR MILITARY ONLY (.mil), Enter alternate (non-military) e-mail address below:Current Assignmen t * e.g. Division, Task Force, Section)Describe Your Current Duties, Role and Responsibilities * POST ID# (Law Enforcement Only) If you don't have this number, please contact your Agency's Training Coordinator.DISCIPLINE / AGENCY TYPE * Law Enforcement Federal Military Tribal Health Fire EMS Private Sector Corrections/Probation/Parole Public Education Other
AGENCY/ORGANIZATION NAME : * Select your agency name below If your agency does not appear above, click "-Other-", then enter your Agency Name below.(no abbreviations) Other Agency/Organization Name:AGENCY ADDRESS Address 1: * Address 2: City: * County * - Select County - Los Angeles Orange Riverside San Luis Obispo Santa Barbara San Bernardino Ventura Other
SUPERVISOR / TRAINING COORDINATOR Full Name: Supervisor AND/OR Training Coordinator (if relevant). Separate by comma and space. * DO NOT LIST SELF Phone: Supervisor AND/OR Training Coordinator (if relevant). Separate by comma and space. *
E-mail: Supervisor AND/OR Training Coordinator (if relevant). Separate by comma and space * (Will receive copy of confirmation ) DO NOT LIST SELF