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:
---
Employed
Full-Time
Part-Time
Unemployed
Retired
Agency Information
Name of Public Safety, Fire/Rescue, EMS, or Emergency Management Employer:
Agency Status:
---
Full-Time
Part-Time
Volunteer
Current Position:
Street:
City:
State:
Zip Code:
Other Information
Race:
---
White
African American
Native American
Hispanic
Asian
Other
Education:
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High School
Adult High School
GED
1 Yr. Voc Diploma
Associate Degree
Bachelor Degree
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: