APPLICATION
CHEMICAL WEAPONS INSTRUCTOR COURSE
September 1
9-20, 2016
BATON ROUGE, LOUISIANA
NAME:____________________________________________________________________________

DEPARTMENT: _____________________________________________________________________

ADDRESS:_________________________________________________________________________

CITY, STATE, ZIP: ____________________________________________________________________

PHONE:___________________________________ FAX:____________________________________

ADDITIONAL NAMES:_________________________________________________________________
___________________________________________________________________________________

___ Class fee of $350.00 per person

___ Register the above name(s) at $350.00 each on department P.O.#____________________________

___ Recertification class Sept
21, 2016 fee of $150.00 per person enclosed

___ Recertification class Sept.
21, 2016 fee of $150.00 per person on Department P.O.#__________



Please make check payable to: Baton Rouge Police Supplies, Inc.
                                      9530 Cortana Place
                                      Baton Rouge, LA  70815

Deadline for Registration is August
31, 2016

___________________________________________       ____________________________________
Authorized Signature                                                                           Date
Baton Rouge Police Supplies, Inc.
9530 Cortana Place
Baton Rouge, LA  70815
225-924-4948
Fax 225-924-4947