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Rank/Title/Position*

Name*

Email Address*

Phone Number*

Agency/Employer*

Agency/ Employer Address*

Agency/ Employer Phone Number*

Agency/Employer Fax Number

Course Requesting* Please Select Defensive Tactics (40 Hour) Defensive Tactics Refresher (8 Hour) ALERRT Level 1 ALERRT First Responser Medical ALERRT Low Light ALERRT Active Attack Integrated Response Part Time 2 Radar/ Lidar Operator Instructor Development Crisis Intervention Training Taser End-User (X26P, X2, X7) Other:

If other, please specify and describe

Preferred Course Location*

ATU Russellville Campus

ATU Ozark Campus

Requester Agency

Estimated Class Size*

Please list three date and time options for the requested course*

Other comments

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