Fentanyl, Bath Salts & Synthetic Drugs
Monday, November 6, 2017
7:00 AM - 5:00 PM
Location: Faith Community Church (Courtesy of West Covina PD)
Directions: 1211 E Badillo Street West Covina, CA

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Only credit card payments accepted for online registrations

 If you paying by check please email cnoaregion3@hotmail.com to make arrangements.

Class Limit 150

STUDENT INFORMATION  *  Required
First Name: *

Last Name: *

Middle Name:
 

Position/Title/Rank:*

YOUR AGENCY / ORGANIZATION NAME*

Work Address*

 
Address 2
 
City:*

State:*

Zip Code:*


CONTACT INFORMATION
Work Phone: (include area code)*

Contact Phone: (include area code)*

Cell Phone: (include area code)
 
 
E-mail:*
 
(Please Use Law Enforcement Agency Email Address)

IDENTIFYING INFORMATION*
Post ID#:   

Date of Birth (mm/dd/yy):*
 
Gender* Male Female
Last four digits of Social Security:*

 

Previous Last Name (enter N/A if the same):



HIGH SCHOOL LAST ATTENDED*

Name of High School*
 
County*
 
State (or Country if outside U.S.)*
 
Years Attended*
 -  
Year Graduated*
 

High School Graduation Status*
 

WHEN DID YOUR PRESENT STAY IN CALIFORNIA BEGIN?*

Approximate date you arrived in California? Enter birth date if always in CA (mm/dd/yy)*



 Law Enforcement Credentials Are Required at Registration

FREE ($10 Admin Fee)

Credit Card Information (all fields required)
Card Type

Cardholder's First Name

Cardholder's Last Name

Credit Card Number

Exp Date
(e.g.: 05/2018)
Security Code

 

Cardholder's Billing Street Address

Billing City

Billing State
(2-digit state code)
Billing Zip Code

Billing Country
(2-digit country code)