Date:

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Course:

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PID:

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Agency:

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First Name:

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Last Name:

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Middle Name:

Date of Birth:

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Sex:

Male

Female

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Ethnic Origin:

Hispanic or Latino Origin

Not Hispanic or Latino Origin

Decline to Answer

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Race Group:

White

Black or African American

Asian

American Indian or Alaskan Native

International

Unknown

Native Hawaiian or Other Pacific Islander

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Permanent Address:

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Please enter your city, county, state, and zip.

Home Phone:

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Cell Phone:

Work Phone:

E-Mail Address:

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Mailing Address:

Classification (Circle One):

1-Texas Peace Officer

3-Licensed Tele-communicator

4-Elected (not licensed)

5-County Jailer

6-Other (no Texas License)

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Paid by (Check One):

Cash

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Bill Agency

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Please Answer (Optional):

Are you academically disadvantaged?

Are you economically disadvantaged?

Do you have disabilities?

Do you have limited English proficiency?

Are you a displaced homemaker?

Are you a single parent?

Have you ever attended Lamar Institute of Technology?

Police Officer In-Service Registration

Course Registration

Regional Police Academy - Certificate