Physical Agility Registration Form

Physical Agility Registration Form

Mr. Dana Phillips, Public Safety Coordinator: dphillips@knoxcc.org
Please pick the date you will be testing*

7/23/2024 @ 6:00 pm7/27/2024 @ 8:00 am
Name*

First NameMiddle NameLast Name
Phone*
e-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number (required)*
Sex*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
U.S. Citizen*

YesNo
FIRE DEPARTMENT AFFILIATION

If NO affiliation type "NONE"
Department:*
Position:*
Fire Department Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fire Department Phone:
Registration Information

You must be registered no later than 5 days prior to the day of testing
Course(s) Registering for:*

Physical Agility Test: Fee $50.00
Payment Information

Payment must be made 5 days prior to the day of testing
Payment :*

Self-PayFire Department
If your Fire Department is paying, you must submit to KTC an original purchase order or a letter of intent signed by the Chief on Department letterhead.

Cash/check/charge payments are accepted. Charge payments can be made by phone to the number below or you can pay in person.*

KTC Phone: 740-393-2933

KTC address: 308 Martinsburg Rd, Mount Vernon OH

Office hours: M-Th 7:30 am - 7:00 pm / Friday 7:30 am - 4:00 pm
*Refunds are available for special circumstances only. You must submit your circumstance in writing and meet with the Public Safety Coordinator. There will be NO refunds after the test date.
Knox Technical Center does not assume any responsibility for any medical consequences that may arise from participating in the PAT. Any candidate under the age of 18 years of age must have a release of liability signed by a parent or legal guardian prior to testing. Forms can be picked up or provided the day of testing. *

I Agree
Should be Empty:

Physical Agility Registration Form

FIRE DEPARTMENT AFFILIATION

Registration Information

Payment Information