STUDENT ENROLLMENT RECORD FORM
NAME:
LAST FIRST M.I.
S.S.N.: (OPTIONAL LAST FOUR DIGITS):
D.O.B.: PLACE OF BIRTH:
ADDRESS: CITY ZIP CODE:
PHONE #:
PLEASE CHECK THE FOLLOWING COURSE(s) THAT YOU MAY TAKE:
ACADEMIC: OHIO PEACE OFFICER TRAINING COMMISSION & ACADEMY (O.P.O.T.C.): ____
REVOLVER: ____
SEMI AUTO PISTOL: ____
SHOT GUN: ____
PEPPER SPRAY: ____
HAZMAT: ____
EXPANDABLE BATON: ____
TASER: ____
ADVANCED SELF DEFENSE: ____
PRIVATE INVESTIGATOR COURSE: ____
THERE IS A $75.00 ENROLLMENT APPLICATION FEE
PLEASE PRINT THIS FORM AND MAIL TO:
THE BRENTLEY INSTITUTE, INC.
P. O. BOX 20724
CLEVELAND, OHIO 44120
OR:
FAX to 216-229-3001
OR: EMAIL THIS FORM TO: BRENTLEY@STRATOS.NET
