SAFE-D Webcast Credit Application

I certify that I participated in the "State of Emergency Services" On-Demand Training and am entitled to receive one (1) hour of ESD Commissioner Training Credit. I understand that false statements on this application may lead to significant penalties.

In the blank below, fill in the keyword supplied during the webcast. The keyword is required for the credit application to be processed.

Please allow 6-8 weeks for credit processing.

Keyword *

Name *

First Name Last Name

E-mail *

County *

ESD Name *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Please rate the value of this training

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Please rate the TECHNICAL QUALITY of this training

Good video/Good audio Good video/Fair audio Good video/Poor audio Fair video/Good audio Poor video/Good audio

Comments about this training?

Use your mouse (on your PC) or your finger (on your mobile device) to sign the form.

Signature

Clear

NEW: BEFORE you click SUBMIT below, click the PRINT FORM button (below) to print the form for your records until you receive an emailed form from VG Young Institute.

Once you hit the SUBMIT button below, you will see an acknowledgement page.

This form will be available for 30 days after the training. After 30 days, credit application will not be available. Please note: Payment must be received for credit hours to be processed. Educational sponsor: V.G. Young Institute of County Government, Texas A&M AgriLife Extension Service.

SAFE-D Credit Application