Financial Fraud Institute
Investigative Operations Division
Federal Law Enforcement Training Center
Department of Homeland Security
Training Those Who Protect Our Homeland
Export Training Financial Reimbursement
Program Name Program Dates
Training Location
Student Name
(Last Name, First Name, MI)
Male
Female
Agency Type:
Federal State Local Other
Department/Agency Name
Department Address:
Mailing Address
City State ZIP Code
EmailOffice Phone Office Fax
Privacy Act Information:
Authority: Title 42, U.S.C. 4742; Title 5, U.S.C. 552;F.R.16586 (March 12, 1981).
Purpose: Obtaining information from individuals applying for enrollment to a
FLETC training program; used for student registration and program administration
purposes.
Uses: Disclosure upon request to individual, the individual's parent agency, to any
other individual or agency at the request of the applicant, to the student locator,
mailroom, registration office, training and research officials, and other government
officials on a need-to-know basis
Effect of Nondisclosure: Supplying the information is voluntary and is not
required by law. Disclosure of your Social Security Number, which is solicited
under authority of E.O. 9397, is voluntary and no right, benefit, or privilege by law
will be denied as a refusal to disclose it. However, failure to provide all or any part
of the information solicited may result in the applicant not being registered for the
requested training program.
RETURN THIS FORM BY FAX TO: (912) 267-2500
Financial Fraud Institute, IOD, FLETC, 1131 Chapel Crossing Road,
Bldg. 381, Glynco, GA 31524
Phone: (912) 267-3166 FAX: (912) 267-2500
This Form Cannot Be Filed Electronically
An actual signature of official authorized to commit funds
is required.
Financial Reimbursement
The agrees to reimburse
the FLETC for the actual cost of training services provided, not to exceed the highest amount of the range projected for this particular program.
Call (912) 267-3166 for the projected cost if necessary. Actual tuition may be less, depending on number of students registered and
adjustments to total cost of training presentation. The FLETC will bill for cost of this training during the month after the program is completed.
The Agency may be billed for the cost of the program if the student slot is canceled within 10 days of the program start. I certify that I am
authorized to approve this obligation of funds by my agency
Credit Card Number
Federal ID Number
Financial Contact Person
Authorized Financial Officer/Purchaser Signature:
Select Program Name from Drop-Down Menu
This form is for export programs only.
It is not to be used for programs at the Glynco, Charleston,
Cheltenham or Artesia Campuses.
(Department/Agency)
Please provide the following information:
Expiration Date
Credit Card: Authorized purchasers will be notified prior to charges assessed to the credit card. An invoice can be provided upon request.
Office of Inspector General Participants: Please note that the IG Academy does not fund slots for FLETC Center Advanced Training
Programs. Funding must be established directly between FLETC and the IG Agency.
Interagency Agreement or Other Funding Arrangement:
If payment is by Interagency Agreement, MOU, or other budgetary mechanism
established by and between your agency and FLETC/Budget, please provide the agreement number.
Agreement
Number
Form will not be processed without signature
Course Number
Cardholder Name Cardholder Phone
Email
Credit Card Information:
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Advanced Asset Forfeiture Training Program
