First Name MI Last Name


Name of agency/work: Agency/work street or PO address  


City State Zip
SSN Date of Birth County of work place


Phone and fax where you can be reached during day hours:

Email address if available:

Phone Fax


level requesting

(check one)

  1. Awareness
  2. Operations
  3. Technician



This certification is


The Department/Supervisor certifies that refresher training has been completed each year and that the individual is certified at level requested



Current Certification #


Department Chief Signature


Signature of applicant Date of application