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, 
If Other specify below:

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 AngelesOrangeRiversideSan Luis ObispoSanta BarbaraSan BernardinoVenturaOther 

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