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23rdCCJARegistrationForm

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23rdCCJARegistrationForm Powered By Docstoc
					          23rd CITIZEN’S CRIMINAL JUSTICE ACADEMY
                   January 12 – March 15, 2012
                              Sponsored by
              PALM BEACH COUNTY CRIMINAL JUSTICE COMMISSION

                         Governmental Center, 10th Floor, Suite 1001
                                   301 N. Olive Avenue
                             West Palm Beach, Florida 33401
                        Tel: (561) 355-4943 Fax: (561) 355-4941
                               E-mail:rmurray@pbcgov.com

                               REGISTRATION FORM
                     (Registration form can be faxed, mailed or e-mailed)

Name:
              Last                                First                 Middle

(Please print your name below as you wish it to appear on your certificate of completion)




Street Address:



City                                        State                 Zip            County

(H)                     (W)                 (C)                   (FAX)
Phone Numbers

E-mail Address:

Preferred method of contact:      Phone                   Fax                    E-mail

Occupation:

Disabled Status:
                     Please indicate whether you have any special requirements

How did you hear about the academy?


Note: Class meets Thursdays from 6:00 – 9:00 p.m.

				
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