Fillable APPLICATION EXAM One application form per evaluation (please (University College of Saint-Boniface)

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APPLICATION EXAM One application form per evaluation (please (University College of Saint-Boniface)

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Country of origin: CANADA
File type: PDF

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___________________________________________________________________________________________________________________
1601 Van Horne Avenue East
Brandon Manitoba
Canada R7A 7K2
Phone: (204) 726-6855
Fax: (204) 726-6847
Toll Free: 1-888-253-1488
mescocr@gov.mb.ca
www.firemedic.ca
STUDENT
EXAM
APPLICATION
FORM
“
Training to Save Lives”
Rev. Dec. 2021
Please ensure that all sections are completed. Incomplete forms will be returned. All personal information contained on this form is necessary for
the efficient operation of the Manitoba Emergency Services College Records Management System and is strictly confidential. It is protected by the
Protection of Privacy provisions of the Freedom of Information and Protection of Privacy Act.
ALL INFORMATON MUST BE COMPLETED OR
THE APPLICATION WILL BE REJECTED AND THE INDIVIDUAL WILL NOT BE REGISTERED ON THE COURSE.
One application form per evaluation (please print clearly)
EXAM TITLE
EXAM DATE
EXAM LOCATION
EVALUATION: Written Practical Level 1 Level 2
REWRITE/RETEST: No 2
nd
Attempt 3
rd
Attempt
Personal Information (as it will appear on MESC correspondence, certificates & documents)
FAMILY NAME
FIRST NAME
Middle Initial
Home Mailing Address
Box Number
Postal Code
/ /
YEAR MONTH DAY
BIRTHDAY
Fire Department/Health Authority and Address
Name
Mailing Address
City/Town/Province
Postal Code
Original Course Information
Original Course Date(s):
Original Course Location:
Instructor:
Date of
Application ______________________________ Signature of Applicant ____________________________
City/Town/Province
Cell Phone
E-mail Address
Emergency Contact Name & Phone:
Indigenous (Persons of
North American Aboriginal ancestry including First Nations
(status and non-status, Inuit and Metis))
Visible Minority (Persons other than indigenous people, who because of their race or
color, are a visible minority.)
Canadian Citizen
Or
Permanent Resident
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APPLICATION EXAM One application form per evaluation (please (University College of Saint-Boniface)

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Completed 22 April 2022

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