3/26/2015SRPSTC

PLEASE TYPE IN THE FIELDS BELOW OR PRINT CLEARLY − FAX OR MAIL TO:

Sacramento Regional Public Safety Training CenterAMERICAN RIVER COLLEGE – LOS RIOS COMMUNITY COLLEGE DISTRICT

5146 Arnold Avenue, Room 110A, McClellan CA 95652(916) 570-5000 Fax (916) 570-5023

srcjtc@arc.losrios.edu (e-mail) http://www.arc.losrios.edu/~safety (web site)

SRPSTC COURSE REGISTRATION FORMFire Technology Law Enforcement Corrections

Course Title: ____________________________________ Course Dates: ___________________________________

Applicant Name: ________________________________ Last 4 SSN: XXX – XX – ___________________________

Mailing Address: ________________________________ Student ID#: ____________________________________

_______________________________________________ Date of Birth: ___________________________________

_______________________________________________ Phone (home/cell): ______________________________

Student E-maill Address: __________________________ Phone (work): __________________________________

Agency/Dept. Name: ______________________________________________________________________________

Agency/Dept. Address: ____________________________________________________________________________

Agency/Dept. Contact: ___________________________ Agency/Dept. Phone: ____________________________

Agency Contact Email Address: _____________________________________________________________________

If using a credit card, please provide the following information:**VERY IMPORTANT NOTE: Please provide the name that appears on the credit card and the billing zip code below.

AGENCY Payment PRINT NAME OF AGENCY/CARD HOLDER:

PRIVATE Payment PRINT NAME OF CARD HOLDER:

Payment Amount: $ __________________________________

Card Number: ______________________________________________________ Expiration Date: _____________

V-Code (The V Code is the 3 digit number on the back of your credit card. The V Code is located in the signature line and isusually the last three numbers directly after your credit card number.) _________________________

Agency Representative or Card Holder Signature: _______________________________________________________

For Office Use Only:

Date Received: ____________ Amount: $ __________ __________ Date Confirmed: _________

Initials: ___________

FEES:∗∗

∗

Fees are subject to change. Verify current fees for ALL courses by calling (916) 570-5000 for assistance.Please make checks payable to American River College.

CANCELLATIONS:Refund/transfer requests must be made, in writing, at least 14 days prior to the first class meeting.

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