Check your FIRST and SECOND priority for the session you wish to attend:

1ST PRIORITY (check one) :     Session 1      Session 2      Session 3      Session 4      Session 5   

2ND PRIORITY (check one) :   Session 1      Session 2      Session 3      Session 4      Session 5       

Participant's Name       Rank

Telephone       FAX      E-mail

Agency Name

Mailing Address

City, State, ZIP

Training Officer Name

Fill out information below if different from above:

Telephone       FAX      E-mail

Mailing Address

City, State, ZIP

Does participant intend to stay at hotel? YES         NO

Has participant completed supervisory training course? YES         NO

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