Bucks County Community College
Department of Public Safety Training and Certification
LOCAL LEVEL COURSE APPLICATION
1760 South Easton Road
Doylestown, PA 18901
This form must be submitted to the Bucks County Community College with at least 8 weeks lead time before proposed starting date.
To be completed by organization requesting the course
Starting Date: Ending Date:
Starting Time: Ending Time:
Indicate any other date / times this course will meet:
Day Telephone No.:
Evening Telephone No.:
Mobile Telephone No:
City, State, Zip:
Course Location (include Street, City, State, Zip):
Is “Live Fire” being used?: YES NO
If Live Fire is being used, list the location of the “live fire” evolution below:
Name and Address of Proposed Instructor
Instructor Contacted: YES NO
Signature of Requesting/Employing Agency Representative (Chief, Training Officer, President, etc.).
Signature also attests that Fire Department’s Insurance carrier provides accident Insurance and workmen’s compensation
coverage for the participants.
SECTION 2: FOR OFFICIAL USE ONLY:
This block may be used by BCCC to list Information specific to record keeping
needs, such as assistant Instructors, course number, etc.
Name and Approval of Agency: Bucks County Community College Department of Public Safety Training & Certification
SECTION 3: PAYMENT INFORMATION:
Organization P.O. (#__________)
All Credit Card payments must complete and submit a Credit
Card Authorization Form, which can be found on our website.
Last Revised: November 9, 2012
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