Contact Information
User Name:
Password:
Full Name (L/F/M):
Certificate Name: ?Certificate Name This field holds the spelling of your name as you want it to appear on your certificate(s).
Email Address:
Phone Number:	999-999-9999
Date of Birth:	* Required for some classes
Social Security: ?Social Security This field holds the LAST 4 digits of your Social Security number.	* Required for some classes
Retired: ?Retired This field indicates whether or not you're retired.	Select One Yes No
Group Affiliation
Group: ?Group Select which group you're a member of (e.g. HIDTA).	None HIDTA
Agency Information
Agency Type: ?Agency Type What type of agency are you currently affiliated with? If none, choose "Civilian".	Select One City Civilian County Federal Local Medical Military Other State Tribal
Agency Size:	Select One No Answer 1-15 16-25 26-50 59-75 76-100 101-150 151-200 201+
LE - Non / Sworn: ?Law Enforcement - Non / Sworn Are you sworn Law Enforcement? If not, choose "Non-Sworn".	Select One Sworn Non-Sworn
LE - Career Level: ?Law Enforcement - Career Level What level of Law Enforcement are you currently at in your career? Examples: Line Level: Officer, Deputy, Corporal Mid-Level: Sergeant, Lieutenant, Captain Executive Level: Major and above	Select One Line Level Mid-Level Executive Level
LE - Years: ?Law Enforcement - Years How many years have you been in Law Enforcement?	Select One No Answer 0-2 3-5 6-10 11-15 16-20 21-25 26+
Assignment Now: ?Assignment Now What is your current assignment?	Select One Active Military Active Reserves Administration Corrections First Responder Investigations Narcotics Other Patrol
Position Title: ?Position Title What is your official title with this agency?
Employing Agency: ?Employing Agency What is the name of the agency you work for?
Address Line 1:
Address Line 2:
Address Line 3:
Zip Code: ?Zip Code Your agency's zip code. City and state are determined from the zip code.
Phone Number:	999-999-9999
Supervisor Information
Supervisor Name: ?Supervisor Name The name of your supervisor or person giving permission to attend courses.
Phone Number: ?Phone Number The phone number of your supervisor or person giving permission to attend courses.	999-999-9999
Email Address: ?Email Address The email address of your supervisor or person giving permission to attend courses.