DRUG OFFENDER EDUCATION PROGRAM REGISTRATION FORM
Which 2011/12 class date do you want to register for: 10/31 - 11/4 11/14 - 11/18 11/28 - 12/2 12/12 - 12/16 12/26 - 12/30 1/9 - 1/13 1/23 - 1/27
Complete the following information:
First Name*
Last Name*
Address
City
Zip
Phone*
E-mail
FAX
Type of intended payment: Credit Card by Internet Credit Card by phone Credit Card in person Check/Money Order by mail Check/Money Order in person
Enter any comments or special needs below:
05/27/2009