REGISTRANT INFORMATION *required First Name: *Last Name: *Position/Title/Rank: * AGENCY / ORGANIZATIONAgency/Organization Name: *Agency Type *Federal State LocalMilitaryOtherIf Other, please specify belowAddress: *City: *
CONTACT INFORMATIONPhone Work: (include area code) * Cell Phone: (include area code)Optional: For Urgent Notifications Email Address:Must be a valid law enforcement / government email address: * Please re-type your email address * Create a Password: * (8 characters - 1 special - 1 numericSUPERVISOR INFORMATIONFor Law Enforcement Status VerificationFull Name*Phone Work* (###-###-####)E-mail* (Provide agency email address)