AERKOAPPLICATION

NAME:____________________________________________________________________________

DEPARTMENT: _____________________________________________________________________

ADDRESS:_________________________________________________________________________

CITY, STATE, ZIP: ____________________________________________________________________

PHONE:___________________________________ FAX:____________________________________

ADDITIONAL NAMES:_________________________________________________________________
___________________________________________________________________________________

___ Class fee of $275.00 per person

___ Register the above name(s) at $275.00 each on department P.O.#____________________________

___ Recertification class fee of $75.00 per person enclosed

___ Recertification class fee of $75.00 per person on department P.O.#___________________________

Hotel Room needed       ___ Yes    ____No

Please make check payable to: Baton Rouge Police Supplies, Inc.
                                                      9269 Florida Blvd., Suite 105
                                                      Baton Rouge, LA 70815

Deadline for Registration is August 20, 2007

___________________________________________       ____________________________________
Authorized Signature                                                                           Date