Public Safety, Fire/Rescue, EMS, or Emergency Management

Identification

Social Security Number:
- -
Confirm Social Security Number:
- -
Date of Birth:
Last Name:
First Name:
Middle Name:

Address

Street:
City:
State:
Zip Code:
County:

Contact Information

Telephone Home:
Telephone Work:
Telephone Cell:
Email Address:

Employment Information

Employment Status:

Agency Information

Name of Public Safety, Fire/Rescue, EMS, or Emergency Management Employer:
Agency Status:
Current Position Title:
Position Type:

Other Information

Race:
Education:
Highest HS Grade Completed:
Title of course you would like to register for:
State if other than NC:

*Also, those persons identified in municipal, county, or state Emergency Operations Plans (EOPs) are qualified for the fee waiver.

Additional Notes or Questions: