Application for Company Officer Certification Appendix F

Office of the
Fire Marshal

Appendix F - Application for
Company Officer Certification

This information is gathered to correctly identify candidates for certification and to evaluate the certification program. Information is being collected solely for the purpose listed above in accordance with the Freedom of Information and Protection of Privacy Act.

Title (please print)	Last name	Given names
Address: (street number and name) (apartment/unit number)
(city) (province) (postal code)	Telephone No. (include area code)	Fax Number (include area code)
Employer (use the four/six digit local code)	Address: (street number and name) (apartment/unit number)
(city) (province) (postal code)	Telephone No. (include area code)	Fax Number (include area code)
If you are successful in obtaining certification, please indicate how you wish your name to appear on your certificate (please print)

Information for evaluation purposes

Age range: q 18-29 years	q30-49 years	q50 or over	Sex F / M	Years of service	qFull-time Firefighter	qVolunteer Firefighter
Education: state highest level completed in terms of years completed
qElementary __________		qSecondary_______	qCommunity college ________		qUniversity ________

Confirm completion of the following requirements for certification. Check all appropriate boxes.

qMinimum 3 years experience as a Company Officer (or Acting Company Officer)
qCompany Officer Diploma. Date received: ___/___/___ Enclose OFC letter of confirmation (MM/DD/YR)	qCertificate of Equivalency Date received: ___/___/___ Enclose OFC letter of confirmation (MM/DD/YR)
qI give permission for the Certification Office to confirm my results with Test Bank Unit	q Job Experience Requirement Performance Checklist (Sign-off sheet only)

I certify that the foregoing statements are true. I am aware that if any of the foregoing statements are willfully false, certification may be denied, revoked or suspended.

_______________________________________________________________ Signature of Individual	___________________________________________ Date
_______________________________________________________________ Signature of Fire Chief	___________________________________________ Date

For Office Use Only

Date received	Cheque number	Certification number
Documentation checked by secretary of Certification Office	Date Reviewed by Council Chairperson	Certification Awarded

FM CERT 01 (06/02)
Return completed form to: Chairperson, Certification Council, Academic Standards & Evaluation Section, Office of the Fire Marshal, 5775 Yonge Street, 7^th Floor, North York, Ontario, M2M 4J1
The above is for reference only. Please use the PDF version for submitting the form. Adobe Acrobat Reader software is freely available at www.adobe.com/acrobat/readstep.html