Physical Agility Registration Form

Physical Agility Registration Form

Mr. Dana Phillips, Public Safety Coordinator: dphillips@knoxcc.org
7/23/2024 @ 6:00 pm7/27/2024 @ 8:00 am
Name*

First NameMiddle NameLast Name
Phone*
Format: (000) 000-0000.
e-mail*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number (required)*
FemaleMale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
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:
Format: (000) 000-0000.
Registration Information

You must be registered no later than 5 days prior to the day of testing
Physical Agility Test: Fee $50.00
Payment Information

Payment must be made 5 days prior to the day of testing
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.
I Agree
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