Course Registration Q Endorsement Course * Q Endorsement - Durham, 2023 Student Name * First Name Last Name Date of Birth * MM DD YYYY Student Email * Student Phone (###) ### #### Student Address * Address 1 Address 2 City State/Province Zip/Postal Code Country CT Driver's License Number * Driver's License Expiration * Department Name * Department Chief or Training Officer * First Name Last Name Chief/Training Officer Email * Chief/Training Officer Phone * (###) ### #### Billing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Payment Method * Invoice from MCFS P.O. Required PO # (if required) Department Authorization * As Chief/Training Officer, I give permission to the member named above to attend and participate in the above noted class. Further, I certify that the above member will be fully covered by this department's insurance for the duration of the class. I also certify that this member has full medical clearance to participate in the class. Yes No Name of Authorizor * First Name Last Name Rank/Title of Authorizor * Thank you! Your submission has been received.
