Exterior, Interior and Full Service Fire Fighter Operations Course Registration Form

Fire Department Name:Fire Department Authorized Contact:

Address:

City: Postal Code:

Email Address:

Designated Online Training Assistantfrom Fire Department Name:

Designated Online Training Assistant Email Address:

The Training Assistant (as "TA" below) will be the member of your department designated by the Fire Department Training Division who will be accessing the online courses as a monitor to guide the students registered in the courses requested below. The named TA is unable to Proctor or Evaluate for the requested program group you have requested below. Please note: The TA cannot be registered as a student.

Course Name Total # Course Cost Total Cost

FIRE-1053 Exterior Fire Fighter Knowledge

FIRE-1054 Exterior Fire Fighter Skills

$ 153.00

TOTAL PAYABLE

Province:

Telephone:

Training Assistant Access code for Jones &Bartlett Online text book Annual Fee

FIRE-1055 Interior Firefighter Knowledge $ 127.50

$ 61.20

First Nations Fire Department(First Nations FD may have funding support through FNESS)

Information to be shared with FNESS

Non First Nations Fire Department

JI Student #: J

FIRE-1056 Interior Fire Fighter Skills

FIRE-1057 Full Service Fire Fighter Knowledge

FIRE-1058 Full Service Fire Fighter Skills

FIRE-1059 Full Service Community Service

GST

$ 61.20

$ 127.50

$ 61.20

$ 25.50

$ 80.00

I understand that my department will be invoiced with the above Total Payable amount when this registration form is being processed.

By signing this form, I am authorizing and approving all of the students listed on the second page of this form in the Student Registration Information section to be registered.

$ 7.65

$ 3.06

$ 6.38

$ 3.06

$ 6.38

$ 3.06

$ 1.28

$ 4.00

Exte

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Inte

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Full

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Date Submitted (mm/dd/yyyy)

Print Name of Fire Department Authorized Contact

Digital Signature of Fire Department Authorized Contact

Course Registration (Please click on all appropriate boxes)

HZMT-1100 Hazardous Materials Emergency Response Awareness Level , click here to register

EMRG-1200 Incident Command System Level 100, click here to register

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Student Registration Information (section)

*Legal Last Name, First Name JIBC Student Number

*Date of Birth(YYYY-MM-DD) *Email Address

Registering Program(s)

Exterior Interior FullService

*Upon completing the registration form, please click on the "submit" button to attachand submit this registration form to the program area via email.

I understand that all students listed below must be from the same Fire Department, and all the programs that apply need to be checked.

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