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Pa State Fire Academy Local Level Course Application

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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:

___

Comments:

Instructor Certified: Yes

No____

Course Certified: Yes____

No____

Field Education Specialist Signature:

Date:

Revision of 1/18/2006

Pa State Fire Academy Local Level Course Application

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