Page 7 - 2016 Instructor Conf Brochure

Iowa Fire Service Instructor’s Conference - November 11 & 12, 2016
Only 1 registration per form (Please duplicate for additional registrations)
Registration Information:
FAX or Mail
Your Registration
First Name Last Name
FAX form to:
Home Address 800-722-7350
Mail completed form with fee to:
City State Zip Instructors Conference
Fire Service Training Bureau
3100 Fire Service Rd
Ames, IA 50011-3100
Fire Department/Company Name
_ _
Registrations will NOT be
Last 4 Digits of SS# Date of Birth (Mo/Day/Yr) Phone Number taken over the phone.
_________________________________________________________________________________________________________
Email

I will attend: (Check one) Registration Fee: (Check all that apply)
Friday Only Conference Fee ($75.00) _________

Saturday Only FSTB Field Instructor (Registration fee paid by FSTB)
Friday and Saturday
IaSFSI Membership Dues: (Not included in Reg. fee paid by FSTB)
Concurrent Sessions: Option 1: $20.00 for 2015
membership dues to IaSFSI __________
1:00 pm - 2:30 pm (Choose 1)
Option 2: $120.00 for 2015
Training Today’s Fire Service membership dues to BOTH the
ResourceOne - Basics and Beyond ISFSI and the IaSFSI __________
Today’s Fire Service Instructor and the Law: TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ __________
An Overview of Hot Topics
Method of Payment:
2:45 pm - 4:15 pm (Choose 1)
Check (Payable to Fire Service Training Bureau)
Training Today’s Fire Service
Bill my Fire Department/Company
ResourceOne - Basics and Beyond
Purchase Order #: ___________________________________
Today’s Fire Service Instructor and the Law:
An Overview of Hot Topics Contact Person: _____________________________________
Billing Address: ______________________________________
All notifications of cancellation must be received in writing. A full
refund will be given before September 17, 2015. No refunds will Visa MasterCard Discover
be made after September 17, 2015.
Card Holder Name:
___________________________________________________
__________________________________________________
Iowa Fair Information Practices Act (Iowa Code Ch 22-11)
Exp Date: _______/________ CVC Code: ___________
The Fire Service Training Bureau requests this information for the
purpose of pre-registering you in a conference. No persons
outside the Fire Service Training Bureau are provided with this Card Number:
information. If you fail to provide the required information, we
cannot assure accurate registration.
__________________________________________________
Signature of Card Holder

Time for Change . . . Moving in a NEW DIRECTION 6