Practical Skills (Reserve Date) Application

 

PRACTICAL SKILLS EXAMINATION APPLICATION

Please PRINT or TYPE all information.  This entire application must be completed prior to submission.

This application MUST be submitted 4 - 6 weeks prior to the examination date

EXAMINATION DATA

Level Requested ( FF 1, FF 2, etc. )

Number of Candidates:

Primary Date:

Alternate Date:

Location of Examination:

Street Address:

City or Town:

REQUESTER DATA

Title

Last Name

First name

Middle Initial

Home Street Address

City or Town

State

Zip Code

Telephone

Home         (                   )

Work  (                  )

ID Number  __ __ __ - __ __ __ __

Level of State of Connecticut Certification

HOST DATA   This examination is being conducted on behalf of:

Organization Name ( i.e. Fire Department, Regional School )

Name and Title of Head of Organization

Telephone Number                                 

Street Address

City or Town

State

Zip Code

Examination Site Point of Contact - Name

Telephone Number

Home                                              Work

Street Address

City or Town

State

Zip Code

Requester’s Signature

Date

Remit completed application to:              Commission on Fire Prevention  and  Control

                                                                Certification Division

                                                                34 Perimeter Road

                                                                Windsor Locks, CT      06096                                  ( 860 ) 627 - 6363

CFPC Use Only:

Exam Date Assigned

Exam Day Assigned