<p> A-RIDE Registration Form (Please print clearly. This information will be used for your certificate and official record.)</p><p>Contact Information Sam Name First Middle Last (Include Jr., Sr., etc.) Houston State TCLEOSE PID*______Date of Birth University Mailing Address Street or Box No. City State Zip</p><p>Work Phone______Fax Number </p><p>ARIDE Pager______Cellular Number Advanced Home Phone______Roadside Impaired Driving E-Mail Address Enforcement Course Peace Officer Status: ___ Full-Time ___Reserve ___Cadet ___Other (If you are a peace officer, check the appropriate box. This for your TCLEOSE Record)</p><p>Verification of SFST: Date(s) Attended: ______BEAUMONT ** Attach copy of Tcledd’s report showing 24 hr SFST course.**</p><p>January 31 – Agency/Company Information February 1, 2012 Agency/Company Name </p><p>Address Street or Box No. City State Zip</p><p>Job Title Course Information THERE IS NO REGISTRATION FEE FOR Course Title____A-RIDE______Credit Hours 16 THIS COURSE Starting Date January 31, 2012 Ending Date February 1, 2012 ______MUST BE SFST PROFICIENT TO ATTEND Course Location 700 North St. Beaumont______TX___ 77701 _ Site Address City State Zip</p><p>Facility Name _ Foundation for Southeast Texas ______</p><p>After completing registration, please e-mail to [email protected] or fax to 936.294.3263.</p><p>Signature ______Date Signed ___ </p><p>A-RIDE Registration\ Student Information 08/07 A-RIDE Registration\ Student Information 08/07</p>