APPLICATION
CHEMICAL WEAPONS INSTRUCTOR COURSE
September 12-14, 2011
BATON ROUGE, LOUISIANA
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NAME:____________________________________________________________________________
DEPARTMENT: _____________________________________________________________________
ADDRESS:_________________________________________________________________________
CITY, STATE, ZIP: ____________________________________________________________________
PHONE:___________________________________ FAX:____________________________________
ADDITIONAL NAMES:_________________________________________________________________
___________________________________________________________________________________
___ Class fee of $300.00 per person
___ Register the above name(s) at $300.00 each on department P.O.#____________________________
___ Recertification class fee of $150.00 per person enclosed
___ Recertification class fee of $150.00 per person on department P.O.#___________________________
Please make check payable to: Baton Rouge Police Supplies, Inc.
9530 Cortana Place
Baton Rouge, LA 70815
Deadline for Registration is September 1, 2011
___________________________________________ ____________________________________
Authorized Signature Date
Baton Rouge Police Supplies, Inc.
9530 Cortana Place
Baton Rouge, LA 70815
225-924-4948
Fax 225-924-4947
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