NAME (Last, First, MI)
TRAINING IDENTIFICATION NUMBER
HOME ADDRESS (Street, PO Box)
CITY STATE ZIP
q CHECK IF NEW ADDRESS q MALE q FEMALE
DAYTIME PHONE EVENING PHONE
FAX # E-MAIL ADDRESS
FIRE DEPARTMENT ID # COUNTY
SPONSORING ORGANIZATION
STREET ADDRESS, PO BOX
CITY STATE ZIP
FD PHONE# FD E-MAIL or FAX
NAME/TITLE - HEAD OF THE SPONSORING AGENCY
SIGNATURE - HEAD OF THE SPONSORING AGENCY (REQUIRED)
Personal Information
Sponsoring Organization
q FIRE ACADEMY COURSE CODE # COURSE TITLE DATES: 1st CHOICE 2nd CHOICE
q REGIONAL COURSE CODE # COURSE TITLE DATES: 1st CHOICE 2nd CHOICE
Please review the application to make certain it is complete and the required payment and prerequisite proof are enclosed.
This form is on the web at www.dhses.ny.gov/ofpc • MAIL OR FAX APPLICATION TO FIRE ACADEMY ONLY
Make checks, money orders & vouchers payable to:
Academy of Fire Science
q VISA q MasterCard q Discover Total Charge: $___________
Card #
Expiration Date Security Code
Signature___________________________________________
Payment Method
_________________________________________ Date _______
q Resident – includes Meals & Lodging
q Commuter – includes breakfast & lunch
q Commuter dinner - $9/day (optional)
Reasonable accommodation request:
________________________________________________
Share room with:__________________________________
Registration Fee (include w/registration)
Materials Fee (if applicable – payable upon arrival)
Accommodations Fee (payable upon arrival)
Optional commuter dinner(s)
$_________
$_________
$_________
$_________
$_________
$_________
Total enclosed:
Balance due upon arrival:
1220 (3/17)
Course Registration -
NOTE: Payment MUST Accompany Registration
Registration Fee is MANDATORY AND NONREFUNDABLE
q NYS Resident - $25 q Out-of State - $50
q Materials Fee (if applicable) payable upon arrival
See course description (may not include required text book)
q Prerequisite Proof (if applicable)
Must accompany registration
Academy Accommodations - payable upon arrival
Registration, Material and Accommodations Fees:
q Check q Money Order
q Signed Voucher q Purchase Order
NOTE: Due to participant demand, the deadline for all Academy course registrations is 20 days before the course start date. If your registration is
not received by this deadline, we cannot guarantee placement in the requested course. Call the Academy for further information.
Registration Form
Fire Academy and Regional Technical Rescue
New York State Academy of Fire Science
600 College Ave., Montour Falls, NY 14865-9634
(607) 535-7136; Fax: (607) 535-4841
Fire Prevention
and Control
click to sign
signature
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