1. Training program title: _____________________________
2. Training program number: _________________________
3. For multiple program offerings, I cannot attend on the following date(s): NOT APPLICABLE
4. Name: Mr. _____ Ms. _____ Mrs. _____
5. Social Security No. Note: Disclosure of your Social Security Number is voluntary. NIC collects Social Security Numbers as an identifier for records of training participants. Executive Order No. 9397.
6. Title Yrs. in position
7. Agency
8. Mailing address
9. City 10. County
11. State 12. Zip code
13. Telephone ( ) Fax ( )
14. E-mail
15. Primary area of corrections (check one):
____1. Adult jail
____2. Adult community corrections
____3. Adult prison
____4. Other (explain): |
16. Type of agency (check one):
____1. Federal - Bureau of Prisons
____2. Federal - Uniformed Services
____3. Federal - Other
____4. State
____5. Local
____6. Regional
____7. U.S. commonwealth or territory
____8. Foreign
____9. Private
17. Agency/institution information:
Institution/facility population
or
Agency population
Total number of agency staff
Number of staff you supervise
18. Training program for team participation? If yes:
____a) each team member must complete an application,
____ b) each team member’s individual supplementary information attached,
____c) list team members below, and
____d) send all applications together.
List team members below:
19. I agree to fully participate in this program. |