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APPLICANT * required
First Name *
Last Name *
Position/Title/Rank *
HIDTA TASKFORCE MEMBER
yes no
IDENTIFYING INFORMATION
Last 4 digits of social security # *
Date of Birth (ie: 04/05/60) *
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 ADDRESS
Address 1:*
Address 2:
City: *
CONTACT INFORMATION
(for registration purposes only)
Phone Work: (include area code) *
Cell Phone: (include area code)
Fax: (include area code)
E-mail: *
Alternate E-mail:
Verify E-mail: *
SUPERVISOR INFORMATION
For Law Enforcement Status Verification
Name of Approving Supervisor: *
Phone Work: (include area code)
E-mail:
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