Candidate Information
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First Name
Last Name
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Email Address
Social Media Name
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Phone Number
Committee Interests?
Please indicate what area you would like to contribute.
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Country that you reside
Town/Providence/Parish
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Department Name
Years in the profession?
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Commanding Officer /Supervisor
Contact Phone Number
Background
Member of a Task Force Team?
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No
Yes
N/A
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Member Affiliation
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CAFF
CAFC
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Level of Education
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Agency Type
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Fire Department
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Current Function/Position
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Firefighter
Chief Fire Officer
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EMS Provider
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Nurse
Area of Responsibility
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Administration Field Operations (Fire)
Command Staff
Communications
Community Emergency Responder
Educational Institute/College
Field Operations (EMS)
Field Operations (Rescue)
Fire, EMS, RescueTraining Division
Hospital
None of the above
Level of Certification Requested?
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Certified Fire Officer
Certified EMS Officer
CERT Trained
Dispatcher/Communications Specialist
Doctor
EMR/First Responder
EMT Basic
EMT Intermediate
EMT-Paramedic
Firefighter
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Rescue Technician
Station Officer
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Certificate/Training
Name of training facility?
Card/Certificate #
Credentialed by?
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National Registry
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Local Training Center
NCTVET
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Career Status?
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Volunteer
Temporary
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Non applicable
Senior Officer Leadership Academy (SOLA)?
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No
Junior Officer Leadership Academy (JOLA)?
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Yes
No
No, but interested
If yes, date attended JOLA?
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Day
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Proof of JOLA Training
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Int'l Trauma Life Support Training?
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Trauma Life Support Date of Completion
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Proof of ITLS/PHTLS/TECC Training
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EMS Credential Expiration?
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EMS Date of Completion
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EMS Training/Certificate
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Current CPR Card (required)
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Other Credential To Support Request
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Other Credentials
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Other Information
CAFC Conference Training Interest?
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Airway Management
Advanced Cardiac Life Support
Advanced Medical Life Support
Active Shooter Training
Basic Life Support
EKG Recognition
Firefighter Skills
Forcible Entry Training
Incident Command System
Leadership Development Training
Live Fire Training
Mass Casualty Training
Pediatric Advanced Life Support
Testing for Credentials
Trauma Management Training
Vehicle Extrication Training/Competition
None/Conference Only
Interested in EMS Competition?
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Yes
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Interested in Firefighter Competition?
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Interested in Extrication Competition?
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Registration (1 certificate emailed, and 1 patch mailed) $5.00 (shipping)
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