2. Today's Date*
   Today's Date
3. Employee Name, ID Number*
4. Shift*
   -- Select One --A-ShiftB-ShiftC-ShiftDay-ShiftVolunteer
6. Attendance Type*
   -- Select One --Attending as a studentAttending as an instructor
8. Course Name*
10. Course Number*
11. Hosting Agency*
13. Course Date(s)*
    Course Date(s) Start Date

    —

    Course Date(s) End Date
14. Course Location Address*
16. City*
17. State*
18. Zip Code
20. Requesting Shift Coverage*
    -- Select One --NoYes
21. If YES, Date(s) & Who Will Cover:*

    If no coverage is needed, type N/A

23. Required Equipment for Class*

    Select all that apply.

    1. Textbook
    2. Computer
    3. Firefighter Gear

    1. SCBA
    2. Spare BA Cylinder
    3. Transportation

    1. Lodging
    2. Per diem
    3. Tuition/Conference Fee
25. Course/Conference Flyer (if available)
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field