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STUDENT INFORMATION * required
First Name *
Last Name *
Position/Title/Rank *
Phone Work: (include area code) *
Cell Phone: (include area code)
E-mail: *
Retype Your E-mail Address: *
HIDTA TASKFORCE MEMBER
Are you a taskforce member?
Yes No
IDENTIFYING INFORMATION
Last 4 digits of social security # or
P.O.S.T. ID # ( or N/A) *
Sworn Law Enforcement Officer
Crime / Intelligence Analyst
Other
(please provide details)
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AGENCY / ORGANIZATION
Agency/Organization Name:
Indicate your agency type *
Federal State Local
Military Other
Agency City: *
SUPERVISOR INFORMATION
For Law Enforcement Status Verification
Full Name
Position/Title/Rank
Phone Work: (include area code)
E-mail:
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