Today's Date:   Course:

Agency:

Agency Address:

City:   State:  Zipcode:

Phone:  Fax:  Email:

Shipping Address for Equipment, Munitions, etc (if different from above):

Shipping Address:

City:   State:  Zipcode:

Phone:  Fax:  Email:

Classroom Address (for Students):

Classroom Address:

City:   State:  Zipcode:

Phone:  Fax:  Email:

How many students (maximum) will the classroom hold?

Agency Point of Contact:

Phone:  Fax:  Email:

Training Dates

Please indicate week/month you would prefer:

1st Choice: Month:  Start Date:  End Date:

2nd Choice: Month:  Start Date:  End Date:

3rd Choice: Month:  Start Date:  End Date:

Any Special On-site Housing or Meal Arrangements for Students and Instructors:

Local Motels:

1. Name:  Phone:  Rate:  Distance from Class:

2. Name:  Phone:  Rate:  Distance from Class:

Closest Major Airport:

Remarks:

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