Angelina College Regional Police Academy

Angelina College Regional Police Academy (Registration Form) Revised 01/01/2016

Last Name: First: Middle Initial:

Male Female Ethic Origin: DOB:

Address: City: State: Zip:

SSN: DL: State: PID#:

Employer: Work Phone: 2nd Phone:

(1) Peace Officer (2) Licensed Telecommunication (3) Jailer (4) Civilian not licensed by TCOLE

Course Title: Course#: Credit Hours: Location: Beg. Date: Tuition: Instructor: Method of Payment: Cash Check Check# Credit Card CC# Expiration Date: Card Type: MC VISA Discover AmExpress Third Party Billing Agency Name:

Billing Address: City: State: Zip:

Name of individual authorizing approved expenditures:

(Print Name and Rank) (Signature) (Date)

Instructions for cancelling course: Each student or their agency is responsible to contact Angelina College 48 hours prior to the class start date for Cancellation. If student or agency neglects to contact Angelina College 48 hours prior to the class start date the registration form will be processed and the student and thier agency will be liable for tuition. Receiving TCOLE Credit: If student has any outstanding debt owed to the Angelina College, student will not be able to register and will not receive TCOLE credit.

Instruction for Registration form: (1) Fill in all blanks of form. (2) Fax form to 936-633-5478, Email to [email protected] or mail to Angelina College Regional Police Academy POB 1768 Lufkin, Tx 75902.

InService Registration & Payment Form Supersedes all previous dated versions 10/01/2014mr