STUDENT ENROLLMENT FORM

NAME:

LAST FIRST M.I.

S.S.N.: (OPTIONAL LAST FOUR DIGITS):

D.O.B.: PLACE OF BIRTH:

ADDRESS: CITY ZIP CODE:

PHONE #: ( ) - EMAIL#:

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: ____

EXECUTIVE PROTECTION:____

CARRY CONCEALED (CCW):____

OTHER LISTED COURSES:_____ (1)

(2)

(3)

(4)

(5)

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