Form_5: BLUECARDINT Annual Instructor Support Form MASTER

CANADIAN, EUROPEAN, AND ASIAN
FIRE DEPARTMENT MEMBERS
Blue Card Annual Instructor Support Program
Department Information
What is the name of the Fire Department or Company?*
Department Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Department Administrator
First Name*
Last Name:*
E-mail*
How many BC Renewals*
Maximum 10 per Submission
For a single department with more than one (1) Blue Card Trainer, the
license renewals will be $2000.00 USD for the first Trainer, $500.00 USD
for each of the second and third Trainers, and $100.00 USD for each
Trainer thereafter.

Blue Card Annual Support Program Trainer No. 1
Blue Card Annual Support Program Trainer No. 1 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 2
Blue Card Annual Support Program Trainer No. 2 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 3
Blue Card Annual Support Program Trainer No. 3 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 4
Blue Card Annual Support Program Trainer No. 4 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 5
Blue Card Annual Support Program Trainer No. 5 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 6
Blue Card Annual Support Program Trainer No. 6 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Renewal No. 7
Blue Card Annual Support Program Trainer No. 7 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 8
Blue Card Annual Support Program Trainer No. 8 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 9
Blue Card Annual Support Program Trainer No. 9 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

Blue Card Annual Support Program Trainer No. 10
Blue Card Annual Support Program Trainer No. 10 Information
First Name:*
Last Name:*
Department Rank:*
Contact Email Address*
Blue Card Username*

STOPPER
Billing Summary
Method of Payment*
Billing Province (if Canada)*
Subtotal
US Funds Excluding GST/HST
Total Purchase
US Funds GST/HST Included
Credit Card purchases include an additional 4% transfer fee.
Total w/Credit Card Charge
US Funds GST/HST + 4% Transfer Fee
Purchase Order No.*
NOTE: All PO Orders are subject to verification.

Credit Card Payment

USDTotal Payment (GST/HST & Credit Card Fee Included)

Payment Method
Credit	Express
Credit	What is PayPal?

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country