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(Revised 7-1-2016)
Louisiana Firefighter & Emergency Responder Certification
Request for Written Examination
Municipal FDID or Industrial ID#: ____________
Thank you for your department’s participation in the Louisiana Firefighter & Emergency Responder Certification Program.
Please complete the information below and return this form 7 days prior to the desired test date. Please note that this form
may be reproduced as needed. The Fire Chief, Administrator, or designate must provide all information requested below in
order for the form to be processed. Incomplete forms will not be considered. Red boxes are required items.
The ___________________________________ Fire Department/Company, in _________________________ Parish, requests a
certification examination for the candidates listed below. Please include the date, time, and location of the examination.
Date: ______________________ Time: _________________ Location: _________________________________
By signing below, the fire chief, administrator, or designate is certifying that the following requirements have been met and
that fire department records will exist to support the fact that each of the following individuals shall/will have:
1. Had a learning experience in each of the subject areas of the course required for certification by the time of the
examination.
2. Achieved satisfactory scores on all local examinations.
3. Demonstrated proficiency in all of the skill evaluations identified for that level of certification by having been observed
and evaluated by a certified Fire Instructor II, approved by LSU FETI to serve as a Lead Evaluator, in the accomplishment
of these skills. Local records are maintained which contain copies of the evaluator’s checklist and evaluation for each
candidate.
4. Met the requirements listed in the appropriate section of NFPA Professional Qualifications.
__________________________________________
Mailing Address (for results and certificates) City State Zip
Phone Number Fax Number Email Address (for results)
Fire Chief or Administrator Training Official or Designate (if applicable)
Signature Signature
(if not using electronic signature, you must sign and scan or fax) (if not using electronic signature, you must sign and scan or fax)
Testing Fees Are Listed Below
Louisiana municipal fire departments:
$20.00 – Hazmat Awareness, Hazmat Operations, Firefighter I, & Firefighter II
$35.00 – All other levels
Out of state municipal fire departments and industrial organizations:
$80.00 – All levels
Please ensure that the participant attends the session approved for and arrives on-time. Organizations will be billed accordingly
for any “no shows” and/or late arrivals.
Complete page 2 of this form, indicating candidates name, last 4 digits of SSN, and exam requested.
(NOTE: Municipal price adjustments listed below effective July 1, 2016)
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