Submit Application To 2016Application For Admission
User Manual: 2016ApplicationForAdmission
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2016 MISSISSIPPI STATE FIRE ACADEMY GENERAL ADMISSION APPLICATION Replaces All Previous Editions. http://www.msfa.ms.gov Submit application to: STATE FIRE ACADEMY 1 Fire Academy USA Jackson, MS 39208-9600 Internal Office Use Only: _________________________ Pay Method: No Fee Bill-After Prepay CASH CK/MO_________________ Date Paid______________ Total Remittance: $____________________ Phone: 601-932-2444; Fax: 601-932-2819 PO#__________________ INV#__________________ Course Fee: $__________________Dorm: __________ Duplicate form as needed. Please Print in Ink or Type Application: Course Date Assigned: __________________________ Applicant, Chief or designee, and one witness must sign application for processing. SECTION 1: APPLICANT INFORMATION Last Name: First Name: Date of Birth Age: And Age Contact Phone Number: Years in Position: Applicant Sex: Male Applicant Status with Department/Organization: digits of SS#) Are you a high school graduate or have a GED? Female Current Position with Sponsoring Department Hire Date: MSFA ID#:(3 letters last name-2 letters first name-last 4 M.I.: YES NO Rank: Career Volunteer Other Student Email Address: SECTION 2: SPONSORING DEPARTMENT/ORGANIZATION INFORMATION Name of Sponsoring Department/Organization: Address: Contact: City, State: Zip: Phone Number: County: Fax: CHECK ALL THAT APPLY Email: City, Federal or State Government Status of Sponsoring Department or Organization: MS Municipal Fire Dept. Career Volunteer Combination MS County Fire Dept. Career Volunteer Combination Industrial Organization For Profit Out of State Law Enforcement Other-Describe_________________________ Appointed Fire Investigator Dispatcher Emergency Management Other SECTION 3: COURSE REGISTRATION AND DORM ACCOMODATIONS Course Name: Requested Date: Course Code: 1st Choice: 2nd Choice: Pre-Requisites Required for this Course: NO Required Pre-Requisite One: List Course Pre-Requisite Course: Agency Certifying Agency Date Completed: Date Completed (Attach copy of certificate) Do you want to reserve a dorm room? NO YES-If Yes, complete section below: Required Pre-Requisite Two: Course: Agency Date Completed: (Attach copy of certificate) YES (If dorm fee is not included in course fee, add $17 per night to course fee) SECTION 4: APPLICANT - Briefly describe your activities or responsibilities as they relate to the course for which you are applying and identify how you will utilize the information obtained from the course. COMPLETE BOTH SIDES MISSISSIPPI STATE FIRE ACADEMY - DIVISION OF MISSISSIPPI INSURANCE DEPARTMENT 2016 MISSISSIPPI STATE FIRE ACADEMY GENERAL ADMISSION APPLICATION Replaces All Previous Editions. http://www.msfa.ms.gov Applicant Name: (Last, First, Middle)__________________________________________ MSFA ID: _______________________________ SECTION 5: FINANCIAL INFORMATION Course Name: If Yes, attach a purchase order or check for the registration process. (Please check catalog course description if unsure.) Group A fee students represent: Mississippi Municipal (career or volunteer) fire departments, Mississippi County (career or volunteer) fire departments, emergency management, military personnel assigned full time to a Mississippi Base, state employees, arson investigators (County Fire Arson and Fire Investigator courses), and Choctaw Fire Department. Is this a pre-payment required course? Group B fee students represent: Industrial organizations, federal affiliates, out-ofstate students, for-profit entities, law enforcement, medical entities, dispatchers, etc. Course Fee: $ Dorm Fee: $17 per night x nights = $ (If applicable and not included in course fee) Meal Fee: $12 per day x days = $ (If applicable and not included in course fee) Book Fee: $ (If applicable and not included in course fee) TOTAL COURSE FEE: $ SECTION 6: SPONSORING DEPARTMENT ACKNOWLEDGEMENT OF APPLICANT PROCESS AND FINANCIAL OBLIGATIONS Signature of approval by chief of fire department or head of organization for applicant to attend course listed. Acknowledgement that a course processing fee of $40 will be charged for all substitutions or cancellations. Additionally, if applicant does not show up for a registered course (regardless of financial responsibility), a fee of $60 will be charged to the sponsoring department/organization. The course fee will be due and paid by organization listed in Section 2 unless marked otherwise below (except the processing fee or no show fee). Please Check One: Signature of Chief or Designee: ________________________________ Department Responsible OR Student Responsible Printed Name: ______________________________________________ Title/Date: Note: If student is responsible, payment must be received 30 days prior to course begin date or student will be removed from the course delivery. SECTION 7: APPLICANT ENDORSEMENT AND CERTIFICATION Do you have any medical conditions which would require special consideration during your attendance? (See American Disabilities Act Federal Regulations in catalog on Rules and Guidelines Governing Students.) NO YES-Explain: A. I certify that the information recorded on this application is correct. I agree to abide by the rules, policies, and regulations of the State Fire Academy of Mississippi if I am admitted as a student. Falsification of information may result in denial of admission or a course certification. B. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge or designee of my organization. All requests for information shall be in writing from said chief officer or designee. C. I understand that the State Fire Academy of Mississippi is not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis. D. I have read and understand all rules and guidelines listed in the catalog governing all students . WAIVER...While attending for the purpose of instruction in the State Fire Academy’s program, (course name) ____________________ and desiring to obtain practical experience by acting in various capacities on the fire apparatus, trucks, and other equipment in connection with my instruction, I (PRINT NAME) ___________________________________ do hereby relieve the State Fire Academy and all agencies or individuals furnishing equipment or services in connection with said school as well as any fellow student or instructor from any and all liability or any sort or nature whatsoever that might arise or occur as a result of any accident, injury, or damage to me during my participation in the course conducted by the State Fire Academy and do, by my presence, assume whatever risk, apparent and unapparent, that training of this entails. I understand that the nature of the tasks a fire fighter will be called upon to perform requires a high degree of physical fitness, agility, and dexterity. The instruction I will receive at the State Fire Academy will, therefore, include rigorous exercises which will require physical fitness, strength, and stamina. I waive any and all claims for myself or my heirs against the Academy, its officials or employees, which may result from my participation in the Fire Academy program. This waiver does not affect any rights I may have pursuant to the Workers Compensation Act or the Tort Claims Act. I hereby agree to follow all Academy Rules and Guidelines Governing Students. IN WITNESS WHEREOF, I AM SIGNING THIS WAIVER IN THE PRESENCE OF THE UNDERSIGNED WITNESS: Witness Signature: _______________________________ Applicant Signature/Date: ________________________________________________ COMPLETE BOTH SIDES MISSISSIPPI STATE FIRE ACADEMY - DIVISION OF MISSISSIPPI INSURANCE DEPARTMENT
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