Recertification Candidate Information
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First Name
Last Name
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Email Address
Social Media Name
*
-
Phone Number
Committee Interests?
*
Country that you reside
Town/Providence/Parish
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Department Name
Years in the profession?
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Supervisor
Contact Phone Number
Background
Member of a Task Force Team?
*
No
Yes
N/A
If Yes, Task Force Name and Country?
Member Affiliation
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CAFF
CAFC
CDEMA
CMO
Military
None
Level of Education
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High School
Secondary School
Associate Degree
Bachelor's Degree
Master's Degree
Post Graduate Degree (PhD, EDD, etc.)
Doctor of Medicine
Agency Type
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Fire Department
Rescue Squad
Community Emergency Response Team
Dispatch Center
Law Enforcement
Ambulance Company
Military
Volunteer Department
Other
Current Function/Position
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Please Select
Firefighter
Chief Fire Officer
Driver Operator
Corporal
Sub Officer
Rescue Specialist
HazMat Specialist
Aircraft Rescue Firefighter
Station Officer
EMS Supervisor
EMS Provider
Lead Firefighter
Medical Doctor
Nurse
Area of Responsibility
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Please Select
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 recertification requested?
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Certified Fire Officer
Certified EMS Officer
CERT Trained
Dispatcher/Communications Specialist
Doctor
EMR/First Responder
EMT-Basic
EMT-Advanced
Paramedic
Firefighter
Junior Fire Officer
Rescue Technician
Station Officer
Proof of Continuing Education Training (24 hours required; meets NCCP standards)
*
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Proof Supporting Recertification Request
Name of Institution Providing Recertification Education
*
Date of Training
Must be between certificate issue date
Program Name/Organization?
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National Registry
Canadian Registry
United Kingdom
University of the West Indies
Local Training Center
NCTVET
Other
Certificate to support training hours (24 hours minimum)
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Certificate to support training hours
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Career Status?
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Volunteer
Temporary
Permanent
Other (seasonal from overseas)
Non applicable
Current CPR Card (Adult, Infant, Child, AED) Front
*
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Current CPR Card (Adult, Infant, Child, AED) Back
*
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Letter from Fire Chief, EMS Director, CMO, Medical Director affirming competency and support for renewal (must have contact information, i.e. email, phone number, mailing address)
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Trauma Life Support Training?
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Please Select
Yes
No
No, but interested
Trauma Life Support Date of Completion
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Month
-
Day
Year
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Certificate
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Initial Issue Date CAFC Registry?
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Month
-
Day
Year
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Initial EMT Certification Date
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Month
-
Day
Year
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Other Information
CAFC Conference Training Interest?
Please Select
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?
*
Please Select
Yes
No
Interested in Attending CAFC Conference next year?
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Yes
No
Other Credentials
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Profile Picture (use your own device)
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Recertification (1 certificate via email and $5.00 admin. fee)
$
30.00
Request new CAFC EMS Patch (based on level) includes shipping
$
10.00
Subtotal
$
0.00
Shipping
$
0.00
Total
$
0.00
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