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ARLEAP PCIS VII Conference Registration
Please fill out all of the questions. When you have completed filling them out, submit them.
If you have any questions or problems pertaining to the form/registration please contact me at
dan.worley@arleap.org
.
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Registration Information
Please enter the following information to register for our event.
First & Last Name
*
Enter your first & last name.
Your answer
Nickname
Preferred name to go by.
Your answer
Certificate Display Name
*
What name would you like to be displayed on your certificate?
Your answer
Phone Number
*
What is the best telephone number to contact you?
Your answer
Email
*
What is the best email address to contact you?
Your answer
Gender (Room Assignments)
*
Male
Female
Prefer not to say
Sworn Status
*
Are you currently or formerly a sworn official?
Yes
No
Spouse
*
Are you the spouse of someone who will be attending PCIS?
Yes
No
Agency Information (Name, address, & phone number)
*
Your answer
Please let us know what type of critical incident you have experienced. Provide non-specific details, leaving out dates, names, and locations.
*
Your answer
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