SUBURBAN LAW ENFORCEMENT ACADEMY
College of DuPage
Registration Form for Basic Academy Credit Program
Name:
Date of Birth:
SS#:
Sex:
Home Address:
City:
State:
Zip Code:
State:
Zip Code:
Employing Agency:
Agency Address:
City:
Agency Phone Number:
Agency Fax Number:
Invoice should be sent to the attention of:
Have you ever taken a course offered by College of DuPage? _______
If yes, was it a credit course? ________
Have you served in the Armed Forces?
____ yes / no ____ Branch: ______________________
Federal Racial/Ethnic Data (required):
1. Are you Hispanic or Latino? (OR Are you of Spanish origin?)
____ Yes Hispanic or Latino
____ Not Hispanic or Latino
2. Are you from one or more of the following racial groups: (Select All that Apply).
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Native Hawaiian or Other Pacific Islander
____ White
____ Choose Not to Respond
3. Please identify your primary racial/ethnic group. (Select One).
____ American Indian or Alaska Native
____ Asian
____ Black or African American
____ Hispanic or Latino
____ Native Hawaiian or Other Pacific Islander
____ White
____ Choose Not to Respond
4. Are you in the United States on a Visa – Nonresident Alien?
____ Yes in the United States on a Visa.
Provide Home Country of Origin: _____________________________
____ Not in the United States on a Visa.
Printed: 5/24/2011