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STUDENT INFORMATION * Required
First Name: *
Last Name: *
Middle Name:
Position/Title/Rank:*
Work Address*
Address 2
City:*
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 First Name (enter N/A if the same):
Previous Last Name (enter N/A if the same):
Previous Middle Name (enter N/A if the same):
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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?* YOUR AGENCY / ORGANIZATION NAME* Local State Federal Military
Agency City:*
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