PSLI REGISTRATION FORM

CHECK ALL 2017 PSLI MODULES THAT APPLY TO THIS REGISTRATION

FISHERS Police Department, Fishers, Indiana
Module 1, April 03 - 07, 2017Module 2, June 05 – 09, 2017Module 3, September 11 - 15, 2017Module 4, October 30 - November 03, 2017

SOUTH BEND Police Department, South Bend, Indiana
Module 1, March 06 - 10, 2017Module 2, May 08 – 12, 2017Module 3, July 31 22 - August 04, 2017Module 4, October 02 - 06, 2017


REGISTRANT DETAILS (Additional Registrants added Below)

Participant First Name (required)

Participant Surname (required)

Department / Organization

Rank / Title

First Name for Badge

Address

Phone/ Fax

Participant Mobile

Participant Email(Required)



ADDITIONAL REGISTRANTS (From same organization/department)

Additional Registrant #1 Details

Additional Registrant #2 Details

Additional Registrant #3 Details

Additional Registrant #4 Details

Additional Registrant #5 Details

Additional Registrant #6 Details

Additional Registrant #7 Details

Additional Registrant #8 Details

Additional Registrant #9 Details

Additional Registrant #10 Details


If you have more than 10 additional registrants please add details in the space below



FEES

• $675 per Module (does not include meals)


CHOOSE A PAYMENT TYPE
Credit CardPurchase OrderCheck - Submit form (below) and send full payment to: PSLI REGISTRATION, P.O. BOX 09626, COLUMBUS, OH 43209


CREDIT CARD DETAILS (Required only if Credit Card option checked above)

Name on Card

Card Number(16 Digits)

Expiration - Month / Year >

Security Code (CVC)


PURCHASE ORDER DETAILS (Required only if Purchase Order option checked above)

Purchase Order #

Contact info for person responsible for payment




CHECK - Submit completed form (below) and send full payment to: PSLI REGISTRATION, P.O. BOX 09626, COLUMBUS, OH 43209


ADD A MESSAGE


CANCELLATION POLICY:
No refund or “carry forward” for “No Shows.”
Cancel more than one week prior to the first day of class, 75% refund.
Cancel less than one week prior to the first day of class, 50% refund.
Cancellations must be made in writing.



Thank You!