Pathfinder On-Line Course Registration

Demographic Information

Name*:

Street Address*:

Street Address:

APO:

City*: State*: New York Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Zip Code*:

Email Address*:

Phone Number*: Home Work Cell

Phone Number2: Home Work Cell

Agency / Professional Information

Agency Name:

Street Address:

City: State: New York Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Zip Code:

Agency Point of Contact:

Agency Phone Number:

Are you a Police Officer?* Select Status Yes No

Are you a Peace Officer?* Select Status Yes No

Are you an EMS Provider?* Select Status Yes No

If yes, Level? Not Certified First Responder Basic EMT Intermediate EMT Critical Care EMT Paramedic Physicians Assistant Physician

State of Issue: Not Certified Nationally Registered New York Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Certification Number:

Expiration Date:

Emergency Information

Emergency Contact:*

Relationship: Telephone:*

Please provide any existing health concerns (including allergies), you wish to share that you feel may be pertinent:

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Course Information

Have you attended any other Pathfinder Operations Courses: Yes No

If yes, please list the courses and dates attended:

Please indicate the class you are registering for today:

Course:* Date(s):*

Course Fee:*

Payment Information

Please note: PRE-PAYMENT of registration fees is required for us to reserve a slot for you in one of our programs. Credit card data is accepted on-line. You may choose to pay for a course using a check or money order, however, credit card must still be provided to reserve your slot. In the event you register indicating you will be paying by a form other than credit card, and you do not show up for the course, your credit card will be billed for the full cost of the course. Please see our cancellation policy below.

Payment method:* Select Payment Method Credit Card Check Money Order Department Purchase Order

Credit Card information*

Credit Card Type: Visa Master Card Discover

Card Number:

Expiration Date: CID #:

Card Holders Name:

Billing Zip Code:

Terms & Conditions

I understand that:

1. Training operations require constant attention toward safety regardless of topic or training location. Additionally, all training on firing ranges (where applicable) depends on careful control of a deadly weapon by each student, and if at any time during the course I am attending my safe behavior and cooperation is not deemed satisfactory to Pathfinder staff, my participation will be terminated and no refund of tuition will be made.
2. I will abide by any and all safety procedures required by Pathfinder Operations, and I agree prior to training to complete, sign and understand a “Release and Indemnification Agreement” releasing Pathfinder Operations, LLC from liability for any injury I may sustain or cause during my training.

Cancellation Policy

• If cancellation is made 30 days or more prior to a scheduled course, a full refund of tuition/fees paid will be made.
• If cancellation is made 14-29 days prior to the start of a scheduled course, Pathfinder will refund 50% of tuition/fees paid.
• If cancellation is made less than 14 days prior to the start of a scheduled course, no refund will be made.
• I understand there will be no refund for no-shows or if dropped from training.
• All cancellations must be made in writing or using our contact form submission.

Rescheduling

If rescheduling is necessary, please contact the Operations Branch ASAP at operations@pathfinder-ops.com.

Electronic Signature

By typing your name and submitting this form you agree that you are submitting an electronic signature authorizing your registration and if selected or defaulted to, a credit card payment.

In complying with the Uniform Electronic Transactions Act ("UETA") released by the National Conference of Commissioners on Uniform State Laws (NCCUSL) in 1999 and the U.S. ESign Act of 2000 where 46 US states, the District of Columbia, and the US Virgin Islands have enacted UETA, we urge you to contact us immediately should you believe this agreement was submitted under false or malicious pretenses.

Pathfinder Operations, LLC takes no responsible for the use, misuse, or any other action pertaining to or related to the transmission of this data beyond the normal processing and use of this data. All submissions are considered confidential and private and will be released on a need to know basis.

Please call or contact us should you have any concerns.

Applicant Name/Electronic Signature:*

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