NORTH CENTRAL GEORGIA LAW ENFORCEMENT ACADEMY
Registration Application Form
(Type or Print Clearly)

Course Name: __________________________________________________________

Course Date: _________________________ Course #: _________________________

Agency: _______________________________________________________________

Address: ______________________________________________________________

City: __________________________ State: _________ Zip Code: ________________

Phone: _________________________________ Fax: ___________________________

Training Officer: _________________________________________________________

Authorizing Official's Signature: ___________________________ Date: ____________

Please register the following students in the order of priority:
Name (please include rank) Social Security Number:

1. _____________________________________         ___________________________

2. _____________________________________         ___________________________

The social security number for each applicant must be included. All applications must also
be signed by an authorizing official for the application to be processed.

Return application to:
Academy Registrar: Faye Stallworth
NCGLEA
5000 Austell - Powder Springs Road
Suite 151
Austell, GA 30106
PH: 770.732.5929
FAX: 770.732.5934

Signup Form 12222003