Ministry of Community Safety and Correctional Services :: Application Form

Appendix D - Application for Firefighter Certification (PDF)

Office of the

Fire Marshal

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)

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)

Fire Department Name/Address: (street number and name)

(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:

18-29 years

30-49 years

50 or over

Sex

F / M

Years of service

Full-time firefighter

Volunteer firefighter

Education: state highest level completed in terms of years completed

Elementary _______________

Secondary _______________

Community college ________

University _______________

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

Continuous service - has been with a fire department(s) continuously with a break of less than 13 weeks

 

Certificate of Achievement: Date received: _____/_______/______ DD / MMM / YYYY

Certificate of Equivalency: Date received: _____/_______/______ DD / MMM / YYYY

I give permission for the Certification Office to confirm my results with Testing Unit Database

Job Experience Requirement Performance Checklist

(Sign-off sheet only)

 

 

Career firefighter requirements

Has served 5,000 hours on duty as an emergency responder

Completed 400 hours of on-the-job training

 

 

 

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

 

 

 

Signature of individual

 

Date 

Signature of fire chief

 

Date

 

For Office Use Only

Date Received

Registration Number

IFSAC Number

Date Reviewed

Certification Coordinator

Certification Awarded

 

FM CERT 02 (11/11)

Return completed form to: Chairperson, Certification Council, Academic Standards & Evaluation Section,

Office of the Fire Marshal,

5775 Yonge Street, 7th Floor,

North York, ON, M2M 4J1