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Office of the
Fire Marshal

Appendix E - Application for
Fire Prevention 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.
 
Last name                                                                                             Given names                                                                                                   Rank
 
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:
 q18-29 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 criteria for certification

Ø        Fire Prevention Officer Diploma

q      Yes

q      No

OR

Ø        Certificate of Equivalency

q      Yes

q      No

If yes, date received :

 

If yes, date received :

 

q      I 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 (mandatory)		 _______________________________________
                               Date

 

 Note:  The Certification Office will notify you within thirty (30) working days of receipt of your Application for Certification if certification has been granted or has been denied, with the reason.

For Office Use Only

Date received

Cheque number

Registration number

Documentation checked by secretary of Certification Office

Date forwarded to Council Chairperson

Date forwarded to Fire Marshal

Certificate number

Date mailed

Not granted: date notification sent

 Return completed form to: Chairperson, Certification Council, Academic Standards & Evaluation Section, Office of the Fire Marshal, 5775 Yonge Street, 7th 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 Get Acrobat Reader