Page 26 - 2015 Annual Fire School Brochure

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Please Print Legibly

91st Annual State Fire School - February 27 - March 1, 2015
Only 1 registration per form (Please duplicate for additional registrations)

Registration Information:

First Name MI Last Name

Home Address

City State Zip

Fire Department/Company Name
_ _
Last 4 Digits of SS# Date of Birth (Mo/Day/Yr) Daytime Phone Number
_ _
______________________________________________________________
Email Cell Phone Number

Iowa Fair Information Practices Act (Iowa Code 22-11). The Fire Service Training Bureau requests this information for the purpose of pre-registering
you in a conference. No persons outside the Training Bureau are routinely provided this information, we cannot assure accurate registration.

Registration & Other Fees/Credits (Check all that apply) Method of Payment:
Check (Payable to Fire Service Training Bureau)
Before February 9, 2015
____ 1 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $85.00 Bill my Fire Department/Company
____ 2 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
Purchase Order #: ___________________________________________

After February 9, 2015 Contact Person: ____________________________________________
____ 1 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00 Billing Address: _____________________________________________
____ 2 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $115.00
Visa MasterCard Discover
Materials Fees: (check if appropriate) Card Number
____ Emergency Vehicle Operator: Fire . . . . . . . . . . . . . . . . . . . . . . $25.00
Exp Date Card CVC #
Training Fund Credit: (Security Code located on the back of card)
____ Interior Fire Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 _________________________________________________________
____ Rapid Intervention Teams (RIT) . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 Print Cardholder Name
____ Manure Pit Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 _________________________________________________________
Cardholder Signature
____ High Angle Rope Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00
____ Grain Bin Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 _________________________________________________________
Cardholder Billing Address
____ Confined Space Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00
____ Trench Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 Please fill out the online fillable Registration Form at
www.dps.state.ia.us/fm/fstb
____ Tractor Rollover/Combine Extrication . . . . . . . . . . . . . . . . . . . -$30.00
____ Industrial Machinery Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 FAX or Mail BOTH pages of the Registration Form
____ Ice Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 FAX form to: 800-722-7350
____ Big Rig Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00
or
Mail completed forms to:
Annual State Fire School
TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________ Fire Service Training Bureau
3100 Fire Service Rd
Ames, IA 50011-3100
Registrations will NOT be taken over the phone.

Registrations will be processed in the order they are received.
Please pay attention to day and times for each class.

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