CERTIFICATION EXAMINATION REQUEST All requests must be received 6 weeks prior to the exam start date. By submitting this request, Lead Evaluators and Hosting agencies agree to comply with all published State Fire Training policies & procedures. Upload request form to: FIRE FIGHTER I Certification Examination Exam Name: FY: Today's Date: Module Type Dates: Retake Dates: # of Students Advertise? Approval Code: Written Yes (Inc. time) Fire Fighter Skills Yes Written Yes (Inc. time) HazMat Skills Yes Written Yes (Inc. time) Wildland Skills Yes Agency/Evaluator Information: Must be administered by an accredited Hosting Agency: ARTP: Yes ALA: Yes ARTP/ALA facility Facility Name: Facility City: Facility Ph: SFT ID# *Include a list of the Registered Lead Evaluator: Skills Evaluators on page 2 Evaluator’s Email: (secure email address to receive random skills) Evaluator’s Phone Number: Contact Name: Phone Number: Contact’s Email or Website Address: (advertised address) Billing Information: Delivery Format Consecutive OR Modular ($10 per unique student) ($10 per unique student per each module) Bill To Agency: Attn: Mailing Address: SFT USE ONLY Retakes Initial Exam Registration Fee Billing Code Type Total Price $10 per Rate * Numb. of Consecutive ($10) OR Modular ($10-30) (5921-59210-142500-15) Candidates retake $ $ Written $ Total # of unique Candidates: _________ # of Candidates: _________ $ $ Skills Total # of unique Candidates: _________ $ Date Returned: All exam materials & exam results are now being collected via your online
CERTIFICATION EXAMINATION REQUEST All requests must be received 6 weeks prior to the exam start date. By submitting this request, Lead Evaluators and Hosting agencies agree to comply with all published State Fire Training policies & procedures. Upload request form to: Exam Name: FIRE FIGHTER I Certification Examination FY: Today's Date: Module Type Dates: Retake Dates: # of Students Advertise? Approval Code: Fire Fighter Written (Inc. time) Yes Skills Yes HazMat Written (Inc. time) Yes Skills Yes Wildland Written (Inc. time) Yes Skills Yes Agency/Evaluator Information: Hosting Agency: ARTP: Yes ALA: Yes Must be administered by an accredited ARTP/ALA facility Facility Name: Facility City: Facility Ph: Lead Evaluator: SFT ID# *Include a list of the Registered Skills Evaluators on page 2 Evaluator’s Email: (secure email address to receive random skills) Evaluator’s Phone Number: Contact Name: Phone Number: Contact’s Email or Website Address: (advertised address) Billing Information: Delivery Format Consecutive ($10 per unique student) OR Modular ($10 per unique student per each module) Bill To Agency: Attn: Mailing Address: SFT USE ONLY Type Registration Fee Consecutive ($10) OR Modular ($10-30) Initial Exam Rate * Numb. of Candidates Retakes $10 per retake Total Price Billing Code (5921-59210-142500-15) Written Total # of unique Candidates: _________ # of Candidates: _________ $ $ $ Skills Total # of unique Candidates: _________ $ $ $ Date Returned: All exam materials & exam results are now being collected via your online
FF.CertExamSchedulingForm.docx