2. First Name**
3. Middle Name
4. Last Name*
6. Address*
7. City*
9. State*
10. Zip Code*
11. Date of Birth (MM/DD/YY)*
13. Phone*
14. Your E-Mail***
16. Name of Business*
18. Employer Position

    1. Bartender/Server/Door Person
    2. Owner/Manager
    3. Package Sales Clerk/Grocery
    4. Other
19. Select the date you wish to attend:
    -- Select One --Wednesday, September, 28th at 9AMFriday, October, 20th at 9AM

    All Classes are held at the Edwardsville Police Department 2nd Floor Training Room.

    333 S Main St, Edwardsville IL 62025

21. *Please enter name information exactly as it appears on your State ID.
23. **Please avoid using corporate e-mails if possible. The certification belongs to you and important class changes will be sent to you personally.
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field