Bucks County Community College
Department of Public Safety Training and Certification
LOCAL LEVEL COURSE APPLICATION
1760 South Easton Road
Doylestown, PA 18901
Ph. 215.340.8417
Fax 215-343-6794
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:
Contact Person:
Day Telephone No.:
Org Name:
Evening Telephone No.:
Address 1:
Mobile Telephone No:
Address 2:
Fax Number:
City, State, Zip:
E-mail Address:
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.
TMP Dept.
Last Revised: November 9, 2012
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