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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 Assignment *
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
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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 *
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 |