Fillable PA STATE FIRE ACADEMY LOCAL LEVEL COURSE APPLICATION (Luzerne County Community College)

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PA STATE FIRE ACADEMY LOCAL LEVEL COURSE APPLICATION (Luzerne County Community College)

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PA STATE FIRE ACADEMY LOCAL LEVEL COURSE APPLICATION
This form must be submitted to an Educational Training agency serving your county listed on the back of this
application. Most institutions require at least 6 weeks lead time before proposed starting date.
To be completed by organization requesting the course
COURSE TITLE: CODE: HOURS:
STARTING DATE: ENDING DATE:
STARTING TIME:
ENDING TIME:
Indicate any other dates/times this course will meet:
Local contact person name & address Telephone; Day-
Telephone; Night-
e-mail-
Fax-
Course location: (include Street, City, State, Zip)
COUNTY: DOH Con-Ed Registration
Requested (check one)
Yes____ No______
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.
DATE:
PART 2: FOR OFFICIAL USE ONLY: This block may be used by the Educational Training Agency (or State Fire Academy) to
list information specific to the ETA’s record keeping needs, such as assistant instructors, ETA course number, etc.
PART 3: TO BE COMPLETED BY THE STATE FIRE ACADEMY:
This attests that the above named instructor is certified to teach the above named course and that the course is an accredited Pennsylvania
State Fire Academy (PSFA) course. Delivery of training, quality control, and supervision of the instructor during the conduct of this course
are the responsibility of the educational training/employing agency. The SFA may exercise quality control oversight of both curriculum and
instructor for program management purposes.
Date form received:
Instructor Certified: Yes
___ No____
Course Certified: Yes____ No____
Comments:
Field Education Specialist Signature: Date:
Revision of 6/16/2014
EDUCATIONAL TRAINING AGENCIES of the STATE FIRE ACADEMY LOCAL LEVEL SYSTEM
ALLEGHENY COUNTY FIRE ACADEMY – 700 West Ridge Road, North Park, Allison Park, PA 15101
(412-931-3158) http://www.county.allegheny.pa.us/emerserv/fireacad/ – All 67 counties.
BERKS COUNTY FIRE TRAINING CENTER – 895 Morgantown Rd. Reading, PA 19607 (610-378-5509)
http://www.co.berks.pa.us/fire/site/default.asp – Berks County.
BUCKS COUNTY COMMUNITY COLLEGE – Emergency Services Training Center, 1760 South Easton
Road, Doylestown, PA 18901 (215-340-8400) http://www.bucks.edu/publicsafety/ – All 67 Counties.
BUTLER COUNTY COMMUNITY COLLEGE (BC3) – Public Safety Training Center - 107 College Drive,
Butler, Pa. 16002. (724-287-8711, ext. 8426). http://www.bc3.edu/publicsafety/fire.asp - All 67 counties.
CAREER TECHNOLOGY CENTER OF LACKAWANNA COUNTY-3201 Rockwell Ave. Scranton, PA
18508-1491 (570-346-8471 ext. 135) http://www.ctc.tec.pa.us Lackawanna, Monroe, Susquehanna,
Wayne, and Wyoming Counties.
CHESTER COUNTY Public Safety Training Campus – 137 Modena Road, Coatesville PA 19320 (610-
344-4100) http://www.chesco.org/index.aspx?NID=1892 - Chester County.
COMMUNITY COLLEGE OF ALLEGHENY COUNTY – Public Safety Institute, 808 Ridge Ave J-217
Pittsburgh, PA 15212 (412.237.2500, fax: 4121.237.4628), email psi@ccac.edu,
http://www.ccac.edu/default.aspx?id=145766 – All 67 Counties.
COMMUNITY COLLEGE OF BEAVER COUNTY – One Campus Drive, Monaca, PA 15061-2588 (724-
480-3447) http://www.ccbc.edu/home.jsp – Beaver County. Upon request: Lawrence and Washington
Counties.
DELAWARE COUNTY COMMUNITY COLLEGE-901 South Media Line Road, Media, PA 19063-(610-
723-4012). www.dccc.edu
DELAWARE COUNTY EMERGENCY SERVICES TRAINING CENTER – 1600 Calcon Hook Road,
Sharon Hill, PA 19079 – (610-237-8630) http://www.delcoestc.org/ – Delaware County.
HARRISBURG AREA COMMUNITY COLLEGE – Shumaker Public Safety Center, 1 HACC Drive,
Harrisburg, PA 17110-2999 – (717-780-2607) http://www.hacc.edu/PublicSafetyCenter/index.cfm – All 67
Counties.
LEHIGH-CARBON COUNTY COMMUNITY COLLEGE – 4525 Educational Park Drive, Schnecksville,
PA 18078 (610-799-1581) http://www.lccc.edu/default.aspx?pageid=575 – All 67 Counties.
LUZERNE COUNTY COMMUNITY COLLEGE- 1333 South Prospect St. Nanticoke, PA 18634 (1-800-
377-5222 or 570-740-0637) http://www.luzerne.edu/publicsafety/ - All 67 Counties.
MONTGOMERY COUNTY COMMUNITY COLLEGE – P.O. Box 400, Blue Bell, PA 19422 (610-619-
7426) http://www.mc3.edu/aa/conted/conted.htm - Lancaster and Montgomery Counties.
MONTGOMERY COUNTY FIRE ACADEMY – 1175 Conshohocken Road, Conshohocken, PA 19428
(610-278-3500) http://www.montcopa.org/index.aspx?nid=136 – Montgomery County.
NORTHAMPTON AREA COMMUNITY COLLEGE – 3835 Green Pond Road, Bethlehem, PA 18017
(610-861-5467) http://www.northampton.edu/Academics/Departments/est/default.htm – All 67 Counties.
PENNSYLVANIA COLLEGE OF TECHNOLOGY SHALETEC, Shale Training & Education Center,
One College Avenue, Williamsport, PA 17701 (570-327-4775) . www.shaletec.org
WESTMORELAND COUNTY COMMUNITY COLLEGE – Public Safety Training Center, 65 Public Safety
Drive, Smithton, PA 15479 (724-872-2447) http://www.wccc.edu/pstc – Fayette, Greene, Indiana,
Washington and Westmoreland Counties.
COURSES CONDUCTED INDEPENDENTLY OF AN EDUCATIONAL TRAINING AGENCY/FIRE
SCHOOL OR
SPONSORED BY A LOCAL JURISDICTION MUST SUBMIT APPLICATIONS TO:
PA STATE FIRE ACADEMY, 1150 RIVERSIDE DRIVE, LEWISTOWN, PA 17044-1979
1-800-459-4096 – 717-248-1115 – FAX 717-248-3580
COURSES CONDUCTED INDEPENDENTLY OF AN EDUCATIONAL TRAINING AGENCY/FIRE SCHOOL OR
SPONSORED BY A LOCAL JURISDICTION MUST SUBMIT APPLICATIONS TO:
PA STATE FIRE ACADEMY, 1150 RIVERSIDE DRIVE, LEWISTOWN, PA 17044-1979
1-800-459-4096 – 717-248-1115 – FAX 717-248-3580
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PA STATE FIRE ACADEMY LOCAL LEVEL COURSE APPLICATION (Luzerne County Community College)

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Completed 26 July 2020

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