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  ONLINE Registration
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ONLINE Registration Form

Bold fields are required

 

First Name:

 

Middle Initial:

 

Last Name:

 

 

Social Security #:

 (Required for Competion Certificates)

Enter only last 6-Digits for Security Purposes:  Example XXX-12-3456

 

Street Address:

  (ie. 123 Anystreet Apt#102)

City:

 

State:

 (ie. TX)

Zip Code:

 

Your Phone #:

 

Alternate Phone #:

 

 

Emergency Contacts Name:

 

Emergency Contacts Phone:

 

 

Employers Name:

 

Employers Phone #:

 

 

Which Academy?:

 (This is the academy you wish to attend)

 

Which Course?:

 

Date of Course Attending?:

 

(ENTER only the first date of class if your course is held over multiple days)

 

Payment Method:

 

 

Type of Credit Card:

 

Credit Card #:

 

Expiration Date:

 

CID #:

 (3 digit code on back of Visa/MC, 4 digit on front of AMEX)

 

Billing Address for Card:

 

Billing Zip Code for Card:

 

BY SUBMITTING THIS REGISTRATION I AGREE

TO PAY THE TOTAL AMOUNT FOR THE COURSE

ACCORDING TO THE CARD ISSUER AGREEMENT.

Your Email Address:

 

   

 

How do you find your CID Number on your Credit Card: 

  AMEX CID (4 digits)                Visa CID (3 digits)              Mastercard CID (3 digits)

amex cid pic.gif          visa cid pic.gif            mastercard cid pic.gif

The academy accepts the following forms of payment;

visa.jpg       mastercard.jpg       americanexpress.jpg        discover.jpg

The Academy accepts CASH, Money Orders, Employer Checks, and all major credit cards.  Including Debit cards.  Secure PayPal payments can be submitted to the following verified email address:  jmcclure@statewidepatrol.com

THE ACADEMY DOES NOT ACCEPT PERSONAL CHECKS!

 

YOU IF SECURED YOUR SPOT BY PROVIDING A CREDIT CARD YOU NEED TO

BRING THE EXACT CREDIT CARD AND YOUR PICTURE I.D. TO THE COURSE.

(FOR SECURITY AND VERIFICATION PURPOSES)

 

DISCLAIMER:  COURSES ARE NON-REFUNDABLE & NON-TRANSFERRABLE.

BE ADVISED, BY SUBMITTING A REGISTRATION FORM & PAYMENT INFORMATION

YOU ARE REQUIRED TO ATTEND THE COURSE FOR WHICH YOU ARE REGISTERED

NO REFUND OR CREDIT FOR FUTURE COURSE(S) WILL BE EXTENDED IF YOU ARE

UNABLE TO ATTEND THE COURSE FOR WHICH YOU ARE REGISTERED.

 

  

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