Personal Information

First Name*

Middle inital

Last Name*

Email*

Last 4 of SS#*

Date of Birth*

Mailing Address*

City*

State*

Zip*

General Admission Information

Fed Student ID Number

Indicate your Affiliation Select One Career Call Volunteer

Home Phone

Work Phone

Cell Phone

Cell Phone Provider (if you wish to get text message course confirmations. (Standard text rates apply) Select One Alltel AT&T Boost Cricket Metro PCS Nextel Sprint Straight Talk T-Mobile US Cellular Verizon Virgin Mobile

Department/Agency Affiliation*

Department/Agency Phone #

Department/Agency Fax #

US Citizen* Select One Yes No

If NO, please indicate country of birth

I certify that the information on this application is correct and understand that falsification of information may result in denial of a course certificate. I understand and agree to abide by the rules, policies, and refund policy of the NH Division of Fire Standards and Training & Emergency Medical Services (NHFSTEMS). I hereby authorize release of any and all information concerning my enrollment in this course to the chief officer in charge or designee of my organization. Unless I am employed by the State of NH, I understand and accept the fact that I am not covered by any insurance provided by the State of NH, the Fire Standards and Training Commission, or any other instructor nor will insurance from any of these agencies be available in the event of my injury or death.* Select One Yes No

Please Type your name to Attest to the Statement*

Date that you Attest to the Statement*