Course Name:

Course Fee Amount:

Date: Hours:

Location: JCCF TCLEOSE CREDIT:

Name: Mr. or Ms. Birth Date:

Agency:

Title:

County:

E-Mail:

Agency Address:

City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Phone: Fax:

1. Are you licensed by TCLEOSE? Yes No

Corrections OR Peace Officer OR Telecommunicator

2. TYPE: 1-Regular 3-Licensed Telecommunicator

4-Elected 5-County Jailer 6-Civilian

3. ETHNICITY - TCLEOSE is required by law to report to the Legislative Budget Board the total number of students by ethnic group, please provide the following information. (Optional)

African American American Indian Asian American

Caucasian Hispanic Other