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

Identification

Datatel ID# or SS#:
Confirm Datatel ID# or SS#:
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

Name of Employer:
Employment Status:

Agency Information

Name of Public Safety, Fire/Rescue, EMS, or Emergency Management Employer:
Agency Status:
Current Position:
Street:
City:
State:
Zip Code:

Other Information

Race:
Education:
Highest HS Grade Completed:
Last Year Attended HS:
Name of Last Highschool Attended:
Title of course you would like to register for:
State if other than NC:
Affliated volunteer or paid member of Fire or Rescue, EMS, Law Enforcement, Emergency Management, or Dispatcher/Telecommunicator. Also, those persons identified in municipal, county, or state Emergency Operations Plans (EOPs) are qualified for the fee waiver.

Additional Notes or Questions: