BURNER CERTIFICATION CHECKOFF SHEET
BURNER Name: ____________________________________________________
Address: ___________________________________________________
___________________________________________________
Business Address: ___________________________________________
___________________________________________
Email Address: ______________________________________________
County: ____________________________________________________
Phone: _____________________________________________________
NC Forest Service Employee: Yes No If yes, what District: ___
1. Date and location of Prescribed Burn School successfully attended:
____________________________________________________________________
____________________________________________________________________
2. Date and location of abbreviated school if answer to #1 was not a Division of Forest
Resources school:
____________________________________________________________________
____________________________________________________________________
3. Burn Observation:
a. Burn plan attached: Yes No
b. Are the following items on the burn plan:
1. Landowner name and address: Yes No
2. Description of burn area: Yes No
3. Map of burn area: Yes No
4. Estimate of fuel tonnage: Yes No
5. Objectives of burn: Yes No
6. Acceptable weather parameters: Yes No
7. Name of certified burner: Yes No
8. Summary of methods to start, control and extinguish: Yes No
9. Provision of notice for nearby persons: Yes No
c. Weather parameters acceptable: Yes No
d. Acceptable manpower and equipment available: Yes No
e. Burn execution acceptable: Yes No
f. Mop-up plan acceptable: Yes No
4. Burn observed by: Signature _____________________________________________
Printed name: __________________________________________
NC Certified Burner #: __________________________________
I hereby recommend that _______________________________________________
be certified as a prescribed burner under the NC Prescribed Burning Act on this date: _________
Comments: ___________________________________________________________
___________________________________________________________
___________________________________________________________
Ma
il to: Gail Bledsoe, Fire Chief
NCDA&CS
1616 Mail Service Center
Raleigh, NC 27699-1600
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