Waiting List Registration

Mini-Auto-Theft Course
Wednesday, April 26, 2017
8:00 AM - 5:00 PM
Location: Irwindale Chamber of Commerce
Directions: 16102 Arrow Hwy Irwindale, CA 91706

Download Flyer

50 Class Limit

STUDENT INFORMATION  *  Required
First Name: *

Last Name: *

Middle Name:
 

Position/Title/Rank:*


Work Address*
 
Address 2
 
City:*

State:*

Zip Code:*


CONTACT INFORMATION
Work Phone: (include area code)*

Contact Phone: (include area code)*

Cell Phone: (include area code)
 
 
E-mail:*
 
(Please Use Law Enforcement Agency Email Address)

IDENTIFYING INFORMATION*
Post ID#:   

Date of Birth (mm/dd/yy):*
 
Gender* Male Female
Last four digits of Social Security:*

 
Previous Last Name (enter N/A if the same):


HIGH SCHOOL LAST ATTENDED*

Name of High School*
 
County*
 
State (or Country if outside U.S.)*
 
Years Attended*
 -  
Year Graduated*
 

High School Graduation Status*
 

WHEN DID YOUR PRESENT STAY IN CALIFORNIA BEGIN?*

Approximate date you arrived in California? Enter birth date if always in CA (mm/dd/yy)*

YOUR AGENCY / ORGANIZATION NAME*




Cost per person: $50

Method of Payment:
 Pay by check or cash the door    Credit Card