Home
PA State Fire Academy Local Level Course Application
This form is to be used to request a PA State Fire Academy local level course. This form will be submitted to the Schuylkill County Emergency Management Agency, which uses Lehigh Carbon Community College as the Educational Training Agency for Schuylkill County.
  Pennsylvania State Fire Academy Local Level Course Listing
Directions
  1. Accurately complete all fields.
  2. Submit the form 6 weeks prior to the date requested.
  3. Print the application confirmation sheet.
  4. You will be contacted within 2 weeks to confirm application.
  5. Contact Jim Misstishin with questions.
COURSE TITLE:  
COURSE CODE:   HOURS:  
STARTING DATE: ENDING DATE:
STARTING TIME:   : (Use 24 hour clock.) ENDING TIME:   : (Use 24 hour clock.)
DOH Con-Ed Registration Requested?  Yes  No
ADDITIONAL MEETING DATES & TIMES
   
COURSE LOCATION DATA
LOCATION NAME:  
STREET:  
CITY:   STATE:   ZIP:  
COUNTY:  
PROPOSED INSTRUCTOR DATA
 I do not have an instructor preference.
 I prefer the following instructor.
NAME:  
STREET:  
CITY:   STATE:   ZIP:  
LOCAL CONTACT DATA
NAME:  
E-MAIL ADDRESS:  
STREET:  
CITY:   STATE:   ZIP:  
PHONE - DAY:  ( ) - PHONE - NIGHT:  ( ) -
FAX:  ( ) -