STUDENT MASTER RECORD INPUT FORM by 1F7dHgk

VIEWS: 5 PAGES: 1

									 FORM                                                             WASHINGTON STATE CRIMINAL JUSTICE
 CJ 1254                                                                      TRAINING COMMISSION
                                 STUDENT MASTER                                       19010 1ST AVE S
 Rev 02/10                                                                      BURIEN, WA 98148-2055
                                   INPUT FORM                                             206-835-7299
                                                                                        Fax 206-835-7921
SSN                                         SESSION NUMBER

LAST NAME                                 FIRST NAME                                 MI

  MALE                               RACE                           DOB
  FEMALE
EMAIL ADDRESS
           @
HOME ADDRESS

CITY                       STATE                       ZIP                 CONTACT PHONE
                                                                           (    )     -


EMERGENCY CONTACT                  RELATIONSHIP                  PHONE #
                                                                 (    )          -


AGENCY                                      HIRE DATE            WORK #
                                                                 (     )    -
AGENCY CONTACT (include title)          CONTACT PHONE            CONTACT E-MAIL
                                        (    )     -                   @
WEAPON MAKE                WEAPON MODEL        WEAPON CALIBER              WEAPON SERIAL #


MILTARY        NONE USA USN                 YEARS OF EDUCATION   DEGREE
               USCG USNG USAF      USMC

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