Greene County HazMat Training Authorization Form
Date
*
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Month
-
Day
Year
Date
Participant Name
*
First Name
Last Name
New York Training ID
*
Participant Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email
*
example@example.com
Prerequisites: HAZMAT FIRST RESPONDER OPERATIONS
Participants Department/Company
*
Please Select
Ashland Fire Dept
Athens Vol. Fire Dept
Cairo Hose Co.
Coxsackie Fire Department
Catskill Fire Department
East Durham Fire Co.
Earlton Fire Department
East Jewett Fire Department
Freehold Vol Fire Co.
Greenville Fire Co.
Haines Falls Fire Co.
H. D. Lane Vol Fire
Hensonville Hose Co.
Jewett Fire Dept.
Kiskatom Fire Dept.
Leeds Hose Co. # 1
Town of Lexington Fire Company Inc.
Hunter Fire Co. # 1
Medway-Grapeville Fire Company
New Balitmore Fire District
Oak Hill Durham Co.
Palenville Fire Dept.
Prattsville Hose Co
Round Top Fire Co.
Tannersville Fire Dept.
Windham Hose Co. No.1
West Athens-Limestreet
Other Type below
Participants Department/Company Other
Chief Officer Name
*
First Name
Last Name
COMPLETE THE APPROPRIATE SECTION BELOW
*
The participant listed is authorized to attend the training indicated and has medical clearance to use Self-Contained Breathing Apparatus (SCBA), in accordance with 29 C.F.R. part 1910.134.
The participant listed is authorized to attend the training indicated and has a medical clearance.
Chief Officer Name Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Chief Officer Email
*
example@example.com
Chief Officer Signature
*
Submit
Should be Empty: