Basic Law Enforcement Training

Instructor Information Sheet

Name ______________________________________________________

Mailing Address: _____________________________________________

____________________________________________________________

Home Phone: ________________________________________________

Work Phone: _________________________________________________

Cell Phone: __________________________________________________

Pager: ______________________________________________________

Email Address: _______________________________________________

Emergency Contact Information:

Name: _______________________________ Relationship: ___________

Address: ___________________________________________________

Phone: _____________________________________________________

******************DO NOT WRITE BELOW THIS LINE *******************

Certifications:

            _________ General Instructor Certificate _______________________

Expiration Date

            _________ Specialized Certificates

                                    _____ Firearms

                                    _____ SCAT

                                    _____ Physical Training

                                    _____ Driver’s Training

                                    _____ CPR Certificate