NAME ____________________________________________________________________

AGENCY AFFILIATION _____________________________________________________

AGENCY PHONE __________________________________________________________

TITLE OF TRAINING(S) ____________________________________________________

__________________________________________________________________________

SITE OF TRAINING(S) _____________________________________________________

DATE OF TRAINING(S) ____________________________________________________

AMOUNT ENCLOSED ___________________________

Will be sent at a later date or on the date of the Training ___________________________

Please return applicable fee to: Nassau/Suffolk Law Services, 1757 Veterans Highway, Suite 50, Islandia, N.Y. 11749 Attn: Cathy Lucidi. This form may also be faxed to Cathy at (631) 232-2489