Please fill out all of the information requested below. You will be contacted for verification of information before your registration is finalized.

Officer's name:

Officer's phone (home):

Officer's phone (work):

Officer's email address: (e.g.: you@aol.com)

Officer's Agency (Name, Address):

 

Officer's Agency Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

Officer's Home Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

School Name:

School Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

Semester Attending:

Course(s) to be taken:

Tuition costs (only):

Reimbursement amount $:

Comments:

Where did you hear about the Law Enforcement Tuition Reimbursement Program?

By submitting this form, I affirm that I am the above stated officer, actively working for the above stated agency. I further understand that it is my responsibility to submit supporting documentation to the CJC to complete the application process.