Page 22 - 2017 Annual Fire School Brochure

Page 1 of 2

93rd Annual State Fire School - February 25-26, 2017

Registration Information:

First Name MI Last Name

Home Address

City State Zip

Fire Department/Company Name
/ / _ _
Last 4 Digits of SS# (Required) 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 6, 2017
____ 1 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $85.00 Bill my Fire Department/Company
____ 2 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00
Purchase Order #: ___________________________________________
After February 6, 2017 Contact Person: ____________________________________________
____ 1 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100.00 Billing Address: _____________________________________________
____ 2 Day Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $115.00
Visa MasterCard Discover
Materials Fees: (check if appropriate)
____ Emergency Vehicle Operator: Fire . . . . . . . . . . . . . . . . . . . . . . $25.00 Card Number
____ Critical Incident Stress Management . . . . . . . . . . . . . . . . . . . . $30.00 Exp Date Card CVC #

Training Fund Credit: _________________________________________________________
____ Forcible Entry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 Print Cardholder Name
____ Interior Fire Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 _________________________________________________________
____ High Angle Rope Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 Cardholder Signature

____ Grain Bin Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 _________________________________________________________
____ Confined Space Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 Cardholder Billing Address
____ Industrial Machinery Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 NOTE: Please DO NOT fill out credit card information if submitting
____ Tractor Rollover/Combine Extrication . . . . . . . . . . . . . . . . . . . -$30.00 this form through email. Payments can be made by phone at
____ Ice Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00 515-294-6817
____ Trench Rescue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -$30.00

TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________ Please complete the online fillable Registration Form on the
Training Opportunities page of our website:
www.dps.state.ia.us/fm/fstb/
Check out our website for more
Course Offerings and Announcements: • Registrations will NOT be taken over the phone.
www.dps.state.ia.us/fm/fstb • Registrations will be processed in the order they are received
• Please pay attention to day and times for each class.
Follow us on Facebook:
https://www.facebook.com/IowaFSTB/