PSS Specialized Classes Request Form

Date

Name

First Last

Email

Interested in (choose one):*

Name of program being requested

Requested start date of course (MUST BE AT LEAST 30 DAYS FROM DATE OF REQUEST)*

Requested date for exam

Level of exam

Type of exam

Desired content and size of exam (for instance, "100 questions, 50 Officer 1 questions and 50 Officer II questions"

Agency Information

Agency name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Location of class*

Estimated enrollment (male/female)*

Lead instructor's name*

Lead instructor's certification # (ODPS)

Instructional cost*

Will the agency be charging students a cost to be collected by the agency?*

If "yes," what is the amount to be charged?

Purchase order information

Authorizing official (name, rank, and phone number)*

Click here to have a price quote sent