NAME: (PLEASE PRINT CLEARLY)
AGENCY ADDRESS:
AGENCY COUNTY AGENCY PHONE NUMBER
Your SSN may be used to verify your status as a Florida law enforcement officer. Failure to give a valid SSN may interfere
with the issuance of a certificate or a claim for salary incentive or mandatory retraining with FDLE. In compliance with
Fl. Statute 119.071, this document serves to notify you of the purpose for the collection and use of your
Social Security Number (SSN). Tallahassee Community College (TCC) collects and uses your SSN only in performance of the
college’s duties and responsibilities. To protect your identity TCC will secure your SSN from unauthorized access and never
release your SSN to unauthorized parties.
I confirm that I am employed by a Florida law enforcement agency as a sworn officer OR a civilian employee whose duties
include investigating, or assisting with the investigation of traffic crashes, or that I am employed by a
Florida State Attorney’s Office AS AN Assistant State Attorney.
51314
FLORIDA PUBLIC SAFETY INSTITUTE
GRANT FUNDED LAW ENFORCEMENT TRAINING
REGISTRATION
STREET ADDRESS
CITY
STATE
ZIP CODE
COURSE TITLE:
DATE OF BIRTH (REQUIRED)
RACE
SEX
FULL SOCIAL SECURITY NUMBER (REQUIRED)
STUDENT'S SIGNATURE
DATE SIGNED
YOUR E-MAIL ADDRESS
LAST NAME
FIRST NAME
M.I.
AGENCY
Select one
Select one
Select one
EMAIL
click to sign
signature
click to edit
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