DEPARTMENT OF HOMELAND SECURITY 

FEDERAL LAW ENFORCEMENT TRAINING CENTERS 

 STUDENT REGISTRATION FORM

Receipt of Student Handbook Acknowledgment

Agency Home Office Information

Driver's License Number:

Emergency Contact

Point of Contact: Work Phone:

Address:

City: State: Zip Code:

Name:

Home Phone: Work Phone:

Home Address:

Home City: Home State: Zip Code:

Relationship:

Email Address:

Duty State: US Citizen:

Birth Date: Sex:

MI:

End Date:

Last Name: First Name:

Social Security Number:

Class: Start Date:

Agency: Arrival Date: Depart Date:

Duty City:

State: Expiration Date:

Home Address:

Home City: Home State: Zip Code:

 

The Federal Law Enforcement Training Centers (FLETC) have standards of conduct and other procedures, policies, guidelines, 

and regulations specifically applicable to students contained in a Student Handbook. The Student Handbook is accessible 

through the following electronic links: 

 

Artesia - https://www.fletc.gov/artesia-student-handbook

Cheltenham - https://www.fletc.gov/cheltenham-student-handbook

Charleston - https://www.fletc.gov/charleston-student-handbook

Glynco - https://www.fletc.gov/glynco-student-handbook

 

I acknowledge that it is my responsibility to familiarize myself with and abide by the standards of conduct, policies, and other 

information contained within the site-specific Student Handbook. I understand that in addition to action taken by my employing 

agency, a violation of the published procedures, policies, guidelines, or regulations may result in discipline up to and including 

expulsion; a permanent ban from current and future enrollment in training programs conducted at the FLETC. 

Signature: Date:

FTC-SEM-30 (07/2016) Page 1 of 2
Privacy Act Statement

Authority 

 

The authority to collect the information is derived from the Government Employees Training Act, 5 USC 

4101-4118 as implemented by Executive Order 11348 of April 20, 1969and Reorganizing Plan No. 26 of 

1950 and the Treasury Department Order No. 140-01(Federal Law Enforcement Training Center), and 

Memorandum of Understanding for the Sponsorship and Operation of the Consolidated Federal law 

Enforcement Training Center. 

 

Purpose and Uses 

 

The information you supply will be used to assist the government in retrieving information documenting your 

training. If you furnish none of the information requested,your attendance in training will be immediately 

terminated. These records and information in the records may be used to: (1) disclose pertinent information 

to appropriate Federal, state, local or foreign agencies responsible for investigating or prosecuting the 

violations of, or for enforcing or implementing, a statute, rule, regulation,order, or license, where the 

disclosing agency becomes aware of an indication of a violation or potential violation of civil or criminal law 

or regulation; (2) disclose information to a Federal, State, or local agency, maintaining civil, criminal or other 

relevant enforcement information or other pertinent information, which has requested information relevant to 

or necessary to the requesting agency's or the bureau's hiring or retention of an individual, or issuance of a 

security clearance, license, contract, grant, or other benefit; (3) disclose information to a court, magistrate, 

or administrative tribunal in the course of presenting evidence. Other routine uses can be found in Privacy 

Act System of Records Notice DHS/ALL-003, Department of Homeland Security General Training Records 

(http://www.gpo.gov/fdsys/pkg/FR-2008-11-25/html/E8-28037.htm). 

 

Effects of Nondisclosure 

 

If you furnish only part of the information required, an attempt will be made to maintain and process your 

records. If the information withheld is found to be essential to effectively maintaining and processing your 

records, you will be so informed, and your training will terminate unless you supply the missing information. 

 

Disclosure of your Social Security Number (SSN) 

 

Solicitation of the SSN is authorized under the provisions of Executive Order 9397 dated November 

23,1943. The SSN will be used only as necessary in connection with retrieving your records. The use of the 

SSN is made necessary because of the large number of present and former students who attend or have 

attended Center Programs, and who potentially may have identical names and birth dates and whose 

identities can only be distinguished by the SSN. 

 

FTC-SEM-30 (07/2016) Page 2 of 2