APPLICATION
CHEMICAL WEAPONS INSTRUCTOR COURSE
September
13-15, 2010
BATON ROUGE, LOUISIANA
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 $100.00 per person enclosed

___ Recertification class fee of $100.00 per person on department P.O.#___________________________

Hotel Room needed       ___ Yes    ____No

Please make check payable to: Baton Rouge Police Supplies, Inc.
                                                   9530 Cortana Place
                                                   Baton Rouge, LA  70815

Deadline for Registration is September 1, 20
10

___________________________________________       ____________________________________
Authorized Signature                                                                           Date
Baton Rouge Police Supplies, Inc.
9530 Cortana Place
Baton Rouge, LA  70815
225-924-4948 - 800-259-4948
Fax 225-924-4947 - 800-259-4947