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Appendix "A"

 

Ontario's triliium logo
Ministry of
Community Safety
and Correctional
Services
 


Office of
the Fire Marshal

ONTARIO FIRE COLLEGE
APPLICATION FOR CERTIFICATE OF COMPLETION
TERRORISM/HAZARDOUS MATERIALS AWARENESS
for First Responders in Ontario:
Self-Study
Instructions for Use:

This form is to be submitted for each student learner requesting a Certificate of Completion.

FAX COMPLETED APPLICATION TO
ONTARIO FIRE COLLEGE
OFFICE OF THE REGISTRAR (705) 687 – 4611

  PART 1 - APPLICANT INFORMATION (Please Print)

 _____________________________________________
  SURNAME               FIRST NAME                INITIAL
 Rank or Position:
 
Please Circle:
MALE     OR    FEMALE
FULL TIME  OR  VOLUNTEER
  Delivery Address:
  City or Town  Prov.  Postal Code Home Telephone #

Terrorism/Hazardous Materials Awareness for First Responders in Ontario: Self-Study
  Course Code

  THM-03-1
  Course Completion Date

 
  PART 2 - FIRE DEPARTMENT or OTHER ORGANIZATION
               DETAILS
  Name  
  Delivery
  Address		  
  City/Town
 
   Province   Postal Code
  Fire Department or Other Organization Telephone Number:   Fire Department or Other Organization Fax Number:


  PART 3 - APPROVAL

I declare that I have completed the Terrorism/Hazardous Materials Awareness for First Responders in Ontario: Self- Study Course

 

   SIGNATURE OF APPLICANT:

I declare that the above-noted student learner has completed the Terrorism/Hazardous Materials Awareness for First Responders in Ontario: Self-Study Course

 

   SIGNATURE OF MANAGER
  OF DESIGNATE: