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Course Information

|Course Title |Course Date(s) |No. of Students |Tuition (per student) |

|      |      |      |$      |

|GRAND TOTAL |$      |

Agency Information

|Point of Contact (Rank/Title, Name):       |

|Agency Name:       |

|Mailing Address:       |City, State:       |ZIP:       |

|Phone No.:       |Fax No.:       |Email Address:       |

|How did you hear about this course? DPS Website Email Flyer TPA Website Other |

Student Information

|Student 1 | Commissioned Non-Commissioned |

|Rank/Title:       |First Name:       |Last Name:       |

|Student 2 | Commissioned Non-Commissioned |

|Rank/Title:       |First Name:       |Last Name:       |

|Student 3 | Commissioned Non-Commissioned |

|Rank/Title:       |First Name:       |Last Name:       |

|Student 4 | Commissioned Non-Commissioned |

|Rank/Title:       |First Name:       |Last Name:       |

Payment Information

|Select method of payment: | Check (Payable to: Texas Police Association) Credit Card |

|Select card type: | MasterCard VISA Discover |

|Credit Card No.:       |Expiration Date:   /   |Security Code (back of card):     |

|Name on Card:       |

|Signature: |Date: |

Please submit this registration form via:

Email: DPS.Training@dps.

Fax: (512)424-5734

Mail: Texas Department of Public Safety, Law Enforcement Education, MSC 0252, PO Box 4087, Austin, TX 78773-0252

For more information, please visit DPS/TPA websites or contact Training staff:

txdps.state.tx.us



(512)424-7214

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