Written Reserve Date Application

Written (Reserve Date) Application

State of Connecticut

COMMISSION ON FIRE PREVENTION AND CONTROL

WRITTEN 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

HOST DATA This examination is being conducted on behalf of:

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

EXAMINATION DATA

Primary Date

Alternate Date

Time of Examination

Location of Examination

Street Address

City or Town

Please indicate the number of applicants per applicable level:

Firefighter I	Fire Officer I	Rescue Technician V&M
Firefighter II	Fire Officer II	Rescue Technician Rope
Fire Service Instructor I	Public Fire and Life Safety Educator I	Airport Firefighter
Fire Service Instructor II	Public Fire and Life Safety Educator II	Rescue Tech – Confined Space
Pump Operator	Health and Safety Officer	Rescue Tech - Trench
Aerial Operator	Incident Safety Officer - Suppression
Tanker Operator	Hazardous Materials Technician

A minimum of 12 applicants are required for local examinations. In the event there are fewer than the required 12 applicants at the exam site, the Commission reserves the right to charge the requesting department or organization an examination administration fee.

As preconditions for this request, the Requester will ensure that the following requirements are met:

1. A minimum of 12 firefighters will be seated for the above examination(s) and each firefighter shall have demonstrated proficiency in all skill evolutions identified for that level of certification, having been observed and evaluated in the accomplishment of those skills by a Certified Fire Service Instructor.

2. Local records concerning the evaluation of candidates are maintained by the Certified Fire Service Instructor, including copies of the checklists and evaluation sheets used in examining the practical skills proficiency of each applicant for certification.

3. All applicants for the examination must carry a form of personal identification during any testing procedure.

4. All applications for the examination must be submitted a minimum of 10 days prior to the examination date requested. New applications must be properly completed and submitted. Applications submitted which are incomplete or not received 10 days prior to the examination date will be rejected.

5. A complete set of directions to the examination location from the nearest major State Route/Interstate Highway are included with this application.

If a check, money order, or purchase order is not enclosed with this application, please complete the following information for billing purposes only ( if applicable ):

BILLING INFORMATION

Name

Organization Name or City/Town

Mailing Address

City or Town

State

Zip Code

REQUESTER DATA

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

By my signature below I certify that I have the authority to request this examination for the named Fire Department, Regional School, or Organization and that all information contained herein is correct to the best of my knowledge.

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