Name: ________________________________________
(Listed name will appear on certificate)
Agency: _______________________________________
Address: _______________City: __________ State: ___ Zip: ____
Tel: (____) _______-_______ Fax: (____) _______-_______
Email: ___________________________
Emergency Contact: __________________________
Relationship: ________________ Tel: (____) _______-_______
Course Requested: ___________________________________
Training Dates: ___________________________________
Hosting Agency: ___________________________________
Billing Information:
P.S.D.I. WILL PROVIDE YOU A RECEIPT ON THE FIRST DAY OF TRAINING
REMIT TUTION TO:
Police Survival and Defense Institute P.O. Box 2053 Skyland, NC 28715
Telephone: 828.713.2775 Fax: 828.676.0731