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Reciprocity Certification Application Form - North Carolina Fire & Rescue Commission Department Of Insurance

North Carolina Fire & Rescue Commission

Department of Insurance

RECIPROCITY CERTIFICATION APPLICATION

Check the option you are applying for:

______ Equivalent/Prerequisite credit - Credit will be on your transcript but you will not receive a NC

Certificate.

______

NC State Certification - Approved applicants will be required to pass an exam with an 80 or better and

will receive a NC certificate.

NC will only grant reciprocity/equivalent/prerequisite credit for IFSAC or Pro Board accredited certificates.

Last 4 Social Security Number: _____________ Date of Birth: _____ /______ /_______

Applicant’s Last Name: _________________________________ First Name: _______________________________________

Primary Fire/Rescue Department Name: ___________________________________________________________________

(Please list full name of Department)

Secondary Fire/Rescue Department Name: _________________________________________________________________

(If Applicable)

(Please list full name of Department)

Sex:

Male

Female Date of High School Graduation or GED: _____________________

***Attach a copy of Diploma/GED/HS Transcript

yyyy

Home Telephone #: (____)_________________ Business #: (____)_________________

Email address: _________________________________________________________

(Required)

Mailing Address: _______________________________________________________

City: __________________________________________

State: __________

Zip: ____________________

County of Residence: ______________________________

Do you have a valid Drivers License ____ YES _____ NO

Have you ever been convicted of an offense against the law other than a minor traffic violation?

(A conviction does not mean you cannot be certified. The offense and how recently you were convicted

will be evaluated in relation to the certification for which you are applying.) _____ YES ____ NO

(If yes, explain fully on an additional sheet and attach to application.)

I certify the above information and attached documentation is true and accurate to the best of my knowledge.

Signature: _______________________________________

Date: ___________________

Please return this form and supporting documents by Email, Fax or U.S. Mail to:

North Carolina Fire and Rescue Commission

Attn: Certifications

1202 Mail Service Center Raleigh, NC 27699-1202

Devin.cockrell@ncdoi.gov

Toll Free: (800) 634-7854 Fax: (919) 662-4670

Revised 4/4/2016

Reciprocity Certification Application Form - North Carolina Fire & Rescue Commission Department Of Insurance

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