STUDENT NAME: ______________________________________________________

(Please Print)                            Last Name                                            First Name                                                   M.I

Social Security # ___________________________________ D.O.B. ______________

Check One Of The Boxes Below:

__________Peace Officer _________ Jailer __________ Civilian ___________Other

Department Name _______________________________________________________

Department Address _____________________________________________________

Call-Back Number (_____) ______________________________

Course Title Date(s) Times

(1) ____________________________________________________________________

(2) ____________________________________________________________________

(3) ____________________________________________________________________

(4) ____________________________________________________________________

If additional personnel would like to enroll in the same class, those names may be added below in lieu of filling out another form.

Name: Social Security # D. O. B.

1.

2.

3.

I hereby attest the above name applicant for enrollment is licensed/employed with our agency. I understand enrollment in the above requires cancellation prior to class-time if student is unable to attend. 979-849-2441 Ext. 2255 or Ext. 2300

 _______________________________________ Date: _______________