 |
Office of the
Fire Marshal |
Appendix D - Application for
Firefighter 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)
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Last name
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Given names
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Address: (street
number and (apartment/unit number)
name)
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(city) (province) (postal code)
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Telephone Number
(include area code)
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Fax Number
(include area code)
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Employer (use the four/six digit local code)
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Address: (street number and name)
(apartment/unit number)
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(city)
(province) (postal code)
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Telephone Number
(include area code)
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Fax Number
(include area code)
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If you are successful in
obtaining certification, please indicate how you wish your name to appear on
your certificate (please print)
|
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Information for evaluation purposes
Age range:
q18-29
years
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q30-49 years
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q50
or over
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Sex
F / M
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Years of service
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qFull-time
firefighter
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q
Volunteer
firefighter
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Education: state highest level completed in
terms of years completed
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qElementary ________
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qSecondary _________
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qCommunity college_________
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qUniversity _________
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Confirm completion of the following requirements for certification.
Check all
appropriate boxes.
qContinuous service - has been with a fire department(s) continuously with a break of
less than 13 weeks
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qCertificate of Achievement Enclose all
three component letters of confirmation
from OFM Test Bank Unit
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qCertificate of Equivalency Date received: ______/_____/_____
( MM / DD / YR)
Enclose OFC letter of confirmation
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qI give permission for the Certification Office
to
confirm my results w/ Test Bank
Unit
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|
qJob Experience Requirement Performance Checklist
(Sign-off sheet only)
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Two endorsed specialty
modules: (not required for those applying the "Window of Opportunity")
Include verification of completion
qMandatory: Pumper Operations: (include verification of completion)
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qOptional: (state the name)
Confined Space Entry and Rescue: Operations Level
Electrical Hazards
Firefighter Emergency Patient Care II
Hazmat: Operations
Level Vehicle Extrication – in specialized situation
Water/Ice Rescue –
includes: land based, water entry and ice rescue
Aerial Operations
|
|
Career firefighter
requirements
qHas served 5,000 hours on duty as an emergency
responder
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qCompleted a minimum of 400 hours of on-the-job
training
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qNon-refundable
fee enclosed with application:
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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
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______________________________________________
Date
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____________________________________________________________________
Signature of Fire Chief
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______________________________________________
Date
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For Office Use Only
Date received
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Cheque number
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Certification number
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Documentation checked by secretary of Certification Office
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Date Reviewed by Council
Chairperson
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Certification Awarded
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FM CERT 01 (06/02) 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
