Texoma Regional Police Academy Registration Form Mandatory information for TCLEOSE reporting Classification: (Please Circle One) 1 – TX P. O. Lic. 3 – Lic. Telecom. 4 – Elected, not lic. 5 – County Jailer 6 – Other, no TX. Lic. Name________________________________________________________ Last (include Jr., Sr., etc.) First Middle Name TCLEOSE PID #____________________________________Date of Birth______________________ S.S.# ____________________________________________ Credit will not be given without above information Home Address: ______________________________________________________________________ Street or Box No. City State Zip Home Phone: ______________________________________________________________________ Agency Information Agency Name: _____________________________________________________ Job Title: _______________________________________________________________________ Agency Address: _____________________________________________________ Street or Box No. City State Zip Agency Phone: _____________________________________________________ Are you currently receiving the monthly training schedules by e-mail? ________ _______ Yes No If no and you want to receive monthly training schedules, please print your e-mail address clearly on the line below. Please notify TRPA if you have a change in your e-mail address. Name preferred on Certificate Grayson County College 6101 Grayson Drive – Denison, TX 75020-8299 Continuing Education Application for Admissions Please Print Legibly SOCIAL SECURITY NUMBER____________________________________________ FULL LEGAL NAME_______________________________________________________________________________________ LAST FIRST MIDDLE ADDRESS____________________________________________________________________________________ MAILING ADDRESS CITY STATE ZIP HOME PHONE NUMBER (_______) ______________________________EMPLOYER NAME_____________________________ WORK PHONE NUMBER (_____) _________________ DATE OF BIRTH____________________________________*ETHNIC ORIGIN__________________*SEX__________________ HAVE YOU ATTENDED GRAYSON COLLEGE BEFORE? _________________________________________________________ CLASSIFICATION: FRESHMAN____ SOPHOMORE_____ ABOVE SOPHOMORE/NO DEGREE_____ WITH DEGREE______ HOW LONG HAVE YOU LIVED IN TEXAS OR OKLAHOMA? ________________ YEARS DRIVERS LICENSE NUMBER____________________________ STATE: ________ EXPIRATION DATE: __________________ WHAT STATE DO YOU CLAIM FOR LEGAL RESIDENCE___________________________COUNTY_____________________ DID YOU GRADUATE FROM HIGH SCHOOL? ______________ GED? _____________ COLLEGE DEGREE? _____________ I certify that the information on this form is true and correct. I will abide by the rules and regulations of Grayson County College. SIGNATURE__________________________________________________________________DATE____________ OFFICE USE ONLY TITLE DATE DAYS TIMES ROOM TUITION AMOUNT________________________________________________________ If Billing your department: Department Name & Billing Address: ___________________________________________________________________________ ___________________________________________________________________________ OFFICE USE ONLY CASH______________________________________DATE__________________________ CHECK#____________________________________INITIALS_______________________ MC: _______________________________________EXP. DATE______________________ VISA: ______________________________________EXP. DATE______________________ *This information is for statistical reporting only. |