FEDERAL LAW ENFORCEMENT TRAINING CENTER



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|Federal Law Enforcement Training Center (FLETC) |

|International Training & Technical Assistance (ITT) |

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|NON-U.S. CITIZEN STUDENT REGISTRATION |

|Voice: (912) 261-3690 Fax: (912) 267-2189 |

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|(PRINT OR TYPE IN ENGLISH) |

|Applicant’s Full Name: (Last Name, First Name & MI) |SEX: |

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| |Male Female |

|Applicant’s Title: |Work Telephone: (Include country/city code) |

|Work Fax Number: (include country/city codes) |Email Address: |

|Ministry or Organization Name: | |

|Mailing Address: | |

|City: |

|Course Dates: |Course Number: |

|Course Title: |

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|FINANCIAL PAYMENT INFORMATION |

|(This section MUST be completed) |

|Card Holder’s Name as it appears on the Credit Card: |Card Holder’s Account Billing Address: |

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|Card Holder’s Telephone Number: (include country/city codes) |Authorizing Signature of Credit Card Holder: |

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|Card Type: |16-Digit Credit Card Number: | |

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|MASTERCARD VISA | | |

|AMERICAN EXPRESS | | |

| |3-Digit Security Code: (located on back of credit card) | |

| |Date Card Expires: (MM/YYYY) | |

|If receipt is requested: FAX RECEIPT MAIL RECEIPT |

|Fax Number: (Include county/city codes) |Mailing Address: |

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|ATTN: |ATTN: |

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|RETURN THIS FORM TO: |The ________________________________________ agrees to reimburse the FLETC for|

| |training services provided. The FLETC will charge the above credit card for |

|International Training & Technical Assistance |the actual cost of training during the month after the program is completed. |

|Federal Law Enforcement Training Center | |

|1131 Chapel Crossing Road |________________________________________________ |

|Building 681, Room B258 |Authorizing Signature (Supervisor or Financial Manager) |

|Glynco, Georgia 31524 | |

REGISTRATION INFORMATION

ADDITIONAL PAYMENT INFORMATION:

Method of payment is due forty-five (45) days prior to arrival at the Federal Law Enforcement Training Center (FLETC). You can remit payment by the following means: Credit Card: MasterCard, VISA, or American Express.

CONFIRMATION:

A confirmation letter with details of the training will be provided upon acceptance into the course. This form is used to REQUEST registration. BEFORE MAKING TRAVEL ARRANGEMENTS, PLEASE ENSURE YOU HAVE BEEN APPROVED FOR ATTENDANCE IN THE REQUESTED COURSE.

STUDENT CANCELLATION FEE:

If for any reason a participant can not attend the program, it is the Center’s policy that International Training & Technical Assistance (ITT) be notified in writing thirty (30) working days prior to the beginning of class.

Cancellations received less than thirty (30) working days before the start date of the training may result in program costs, in full or partial, being billed regardless of attendance.

PURPOSE:

The purpose of this form is to obtain student registration and payment information from non-U.S. Citizens attending training conducted at the Federal Law Enforcement Training Center (FLETC).

EFFECT OF NON-DISCLOSURE:

Not providing all or any part of the requested information may result in the applicant not being registered for the requested program.

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