Online Registration Form

Online Registration Form

Police Training Institute, Inc.
31 Grove Avenue, Cincinnati, Ohio 45246
(513) 772-5994

Student Information

Name		Rank
Birthdate		Social Security #
Full Time	Part Time	Reserve	Auxiliary
Daytime Phone#		E-mail
Agency
Agency Street Address
Agency City	Agency County	Agency State	Agency Zip Code

Course / Reservation Information

Course Title

Do you have any medical condition we should know about?

If yes, please explain fully.

Billing Information

Name		Rank
Agency
Agency Street Address
Agency City	Agency County	Agency State	Agency Zip Code

Agreement

Police Training Institute, Inc. will provide instruction in the course under competent supervision and assumes no responsibility other than the opportunity to learn under supervision. Acceptance of enrollment in a course constitutes an agreement to the conditions stated. Police Training Institute, Inc. is hereby relieved of all liability. All courses are subject to cancellation. Cancellation notice must be provided not less than seventy-two (72) hours to the scheduled date for a credit to be issued.

Applicant Acknowledgement

Authorizing Supervisor

Date of Submitted

By clicking the SUBMIT button below, you confirm your acceptance of this agreement in its entirety and enroll in the class specified above. An invoice will be sent to your agency for billing shortly after submission of this form.

Reproduction without the express, written permission of Police Training Institute is expressly prohibited.