COURSE CODE L-273 Managing Floodplain Development through the Virginia Department of Conservation and Recreation COURSE TITLE TRAINING APPLICATION FORM National Flood Insurance Program (NFIP) King & Queen Public Library, 396 COURSE LOCATION Newtown Rd., St. Stephens Name (Last, First) Church, VA 23148 COURSE DATES April 24 to April 27, 2017 Current Position/Title: Jurisdiction (Specify city/county or choose from the following: State Agency, Federal Agency, or Private Organization): Mailing Address: (Work): Phone (alternate): Fax Number: Address: Discipline: Emergency Floodplain Manager Code Enforcement/Inspection Management Private Planning Consultant Community Municipal Manager Official Engineering Public Works (Please Specify): Briefly describe your activities/responsibilities as they relate to the course Do you have any disabilities (including special allergies or medical disabilities) which would require special assistance during your attendance at the training course? If so, please describe: I certify that the information recorded on this application is correct. Applicant Signature: Date: TO APPLY, PLEASE EMAIL, MAIL, OR FAX THIS APPLICATION TO: Virginia Department of Conservation & Recreation Attention: Charley Banks 600 East Main Street, 4th Floor Richmond, VA 23219 Phone Number: 804-371-6135 Fax Number: 804-371-2630
COURSE CODE L-273 COURSE TITLE Managing Floodplain Development through the National Flood Insurance Program (NFIP) COURSE LOCATION King & Queen Public Library, 396 Newtown Rd., St. Stephens Church, VA 23148 COURSE DATES April 24 to April 27, 2017 Virginia Department of Conservation and Recreation TRAINING APPLICATION FORM Name (Last, First) Current Position/Title: Jurisdiction (Specify city/county or choose from the following: State Agency, Federal Agency, or Private Organization): Mailing Address: (Work): Phone (alternate): Fax Number: Address: Discipline: Floodplain Manager Code Enforcement/Inspection Planning Municipal Manager Public Works Emergency Management Private Consultant Community Official Engineering (Please Specify): Briefly describe your activities/responsibilities as they relate to the course Do you have any disabilities (including special allergies or medical disabilities) which would require special assistance during your attendance at the training course? If so, please describe: I certify that the information recorded on this application is correct. Applicant Signature: Date: TO APPLY, PLEASE EMAIL, MAIL, OR FAX THIS APPLICATION TO: Virginia Department of Conservation & Recreation Attention: Charley Banks 600 East Main Street, 4th Floor Richmond, VA 23219 Phone Number: 804-371-6135 Fax Number: 804-371-2630
DCR199-242.docx