Fill - Free fillable Evaluator Application Fillable PDF form

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LouisianaStateUniversity

CarrolL.HerringFire&EmergencyTrainingInstituteCertification

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6868NicholsonDrive ● BatonRouge,LA70820

Office:225‐334‐6282Fax:225‐334‐6065

NewCertificationEvaluatorApplicationForm

ThankyouforyourwillingnesstoserveasanevaluatorfortheLouisianaFirefighterandEmergencyResponderCertificationProgram.

Pleasecompletethefollowingrequirementstobegintheprocess:

Step1(REQUIRED):SubmittheLouisianaFirefighterandEmergencyResponderCertificationProgramProctorApplicationForm.

Step2(REQUIRED):AttendaLouisianaFireFighterandEmergencyResponderCertificationEvaluatorTrainingWorkshop.

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Shouldyouhavequestionsregardingthisform,e‐mailfeticert@lsu.edu.HoursofoperationareM‐F,8‐4:30CST.

NEWAPPLICANTINFORMATION

LastName 

First

Name

 

Middle

Initial



Title/Job

Description



Agency

Representing

(canlistmultiple)



Training

AffiliationPolicy

TheLouisianaFirefighterandEmergencyResponderCertificationProgramdoesnotsupportevaluator(s)

administeringskillstestingtoindividuals(s)onasubjectareathattheevaluatorwasinvolvedinthetrainingof

saidindividual(s).Thisappliestoperson(s)notonlyinthesamedepartmentastheevaluator,butalsonon

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departmentperson(s).Aviolationofthispolicywillresultinthedisqualificationofevaluatorstatusanda

possiblesuspensionoffuturecertificationtesting.

AgencyAddress

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City  State  Zip 

Home

Address



City  State  Zip 

Email  PhoneContact 

SecondaryEmail  SecondaryPhone 

Workshopselection

(mustattendone,spaceslimitedateach)

 11/07/18

(BatonRouge)

 11/14/18

(PineCountry)

 12/15/18

(BatonRouge)

DateWorkshop

Attended(OFFICEUSEONLY)

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NEWEVALUATORCOMMITMENT

Bymysignaturebelow,IattestthatIwillcomplete allrequiredtrainingassetforthbytheLouisianaFirefighterandEmergency

ResponderCertificationProgram,thatImeettheeligibilityrequirementsofbecomingaCertificationevaluatorforthestateof

Louisiana,andamwillingtoassumetheresponsibilitytoserveas

aLouisianaFirefighterandEmergencyResponderCertification

ProgramevaluatorofpracticalskillsforCertification.Asanauthorizedevaluator,IguaranteethatIwilladheretoaprofessional

standardwhenservingandIagreetoconductthepracticalskillstestinginaccordancewiththepolicies,responsibilitiesand

proceduresoutlinedintheLouisiana

FirefighterandEmergencyResponderCertificationProgrammanual.Mostimportantly,bymy

signaturebelow,IconfirmandunderstandthatIcannotandwillnotevaluateanyindividualsonalevelthatIwasinvolvedinthe

instructionofforsaidindividuals.IalsounderstandbythisagreementthattheLouisianaFirefighter

andEmergencyResponder

CertificationProgrammaycontactmeforverificationpurposes,conductrandomspotchecks,andIgrantpermissionforverificationo

mycredentials.Arenewalform,alongwithaworkshop,mustbecompletedeveryotheryearforrenewal.

Signature  Date 

Pleasesignandsubmitthisapplication formandreturntothe

CarrolL.HerringFireandEmergencyTrainingInstitute–CertificationProgram–fax:225.334.6065;orbyemailatfeticert@lsu.edu

Revised 05/03/2018

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