CLASS INFORMATION

CLASS INTERESTED IN

Other (Add Class Name Below) Dive Rescue 1 Dive Rescue Seminar @ CLC Fire Apparatus Engineer Confined Space/Trench Awareness Confined Space Tech Vertical I Vertical II Haz-Mat Ops Haz-Mat Tech Haz-Mat Incident Command Structural Collapse Ops Structural Collapse Tech Roadway Extrication Specialist Fire Prevention Officer Fire Investigator Arson Investigator Juvenile Fire Setters

OTHER CLASS

DATE(S) OF CLASS

REGISTRANTS INFORMATION

NAME

FIRE OR RESCUE DEPARTMENT

Pick Your Department OTHER (Add Department Name Below) Abbott FD Antioch FD Antioch Rescue Barrington FD Beach Park FD Buffalo Grove FD Countryside FD Deerfield-Bannockburn FD Fox Lake FD Grayslake FD Great Lakes FD Gurnee FD Highland Park FD Knollwood FD Lake Bluff FD Lake Forest FD Lake Villa FD Lake Villa Rescue Lake Zurich FD Libertyville FD Lincolnshire-Riverwoods FD Long Grove FD Mundelein FD Newport FD North Chicago FD Round Lake FD Wauconda FD Waukegan FD Wheeling FD Winthrop Harbor FD Zion FD

OTHER FIRE OR RESCUE DEPARTMENT

YOUR WORKING SHIFT (Check all that apply)

BLACK SHIFTRED SHIFTGOLD SHIFTDAY SHIFTPART TIMEWEEKENDSEVENINGSNO SET SCHEDULE

CONTACT NUMBER

HOMEMOBILEWORKFAX

TRAINING OFFICER

FIRE/RESCUE PHONE NUMBER (NON-EMERGENCY)

GROUP INFORMATION

» USE THIS AREA TO REGISTER MULTIPLE MEMBERS OF YOUR DEPARTMENT «

ADDITIONAL MEMBERS OF YOUR DEPARTMENT REGISTERING

List Other Members Here

TRAINING OFFICER HAS CONSENTED TO THIS TRAINING        YES

PAYMENT INFORMATION (If Applicable)

COST OF CLASS PER STUDENT

PURCHASE ORDER NUMBER