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I AGREE TO ABIDE BY THE RULES AND POLICIES OF THE ARKANSAS FIRE TRAINING ACADEMY IF I AM ADMITTED AS A STUDENT. ARKANSAS FIRE ACADEMY Application for Admission PERSONAL INFORMATION NAME Last First Middle HOME ADDRESS Number Street or Box City State Zip PHONE NUMBERS WORK DATE OF BIRTH SOCIAL SECURITY NO. I UNDERSTAND THAT THE ARKANSAS FIRE TRAINING ACADEMY DOES NOT PROVIDE MEDICAL OR HEALTH INSURANCE FOR STUDENTS. I MAINTAIN APPROPRIATE INSURANCE ON AN INDIVIDUAL BASIS. STUDENT DISPOSITION ACCEPTED Enrollment Division Use Only REJECTED REASON Signature TRN001 Arkansas Fire Academy Application Form Date June 21 2010. 479 751-4510 HOME SE X OTHER PLEASE CHECK THE RACE/NATIONAL ORIGIN WHICH BEST APPLIES TO YOU Caucasian Black HIGH SCHOOL or GED YES MALE Asian FEMALE Hispanic Indian CIRCLE NUMBER FOR HIGHEST LEVEL OF FORMAL EDUCATION NO High School 9 10 11 12 College 13 14 15 16 Post Graduate 17 18 19 20 DO YOU HAVE ANY HANDICAPS INCLUDING SPECIAL ALLERGIES OR MEDICAL CONDITIONS WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE AT AFTA If YES explain here. COURSE INFORMATION ENTER THE COURSE YOU WISH TO TAKE Name Location Date Name of Course Course Location ORGANIZATIONAL INFORMATION FDID NUMBER NAME OF FIRE DEPARTMENT 72300 DEPT. TELEPHONE NO. Springdale Fire Department FULL DEPARTMENT ADDRESS APPROVAL BY CHIEF OR TRAINING OFFICER PO Box 1521 Springdale AR 72765 SIGNATURE DATE TITLE Battalion Chief Training Officer I CERTIFY THAT THE INFORMATION RECORDED ON THIS APPLICATION IS CORRECT. FALSIFICATION OF INFORMATION MAY RESULT IN DENIAL OF ADMISSION* BY SIGNING THIS APPLICATION THE STUDENT AGREES TO ALLOW THE ACADEMY TO MAIL THE CERTIFICATE TO HIS/HER DEPARTMENT. AFTER THAT TIME THE RELEASE OF INFORMATION ABOUT COMPLETION OF THIS COURSE AND CREDIT FOR IT WILL BE MADE ONLY UPON SIGNED PERMISSION BY THE STUDENT. 479 751-4510 HOME SE X OTHER PLEASE CHECK THE RACE/NATIONAL ORIGIN WHICH BEST APPLIES TO YOU Caucasian Black HIGH SCHOOL or GED YES MALE Asian FEMALE Hispanic Indian CIRCLE NUMBER FOR HIGHEST LEVEL OF FORMAL EDUCATION NO High School 9 10 11 12 College 13 14 15 16 Post Graduate 17 18 19 20 DO YOU HAVE ANY HANDICAPS INCLUDING SPECIAL ALLERGIES OR MEDICAL CONDITIONS WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE AT AFTA If YES explain here. COURSE INFORMATION ENTER THE COURSE YOU WISH TO TAKE Name Location Date Name of Course Course Location ORGANIZATIONAL INFORMATION FDID NUMBER NAME OF FIRE DEPARTMENT 72300 DEPT. COURSE INFORMATION ENTER THE COURSE YOU WISH TO TAKE Name Location Date Name of Course Course Location ORGANIZATIONAL INFORMATION FDID NUMBER NAME OF FIRE DEPARTMENT 72300 DEPT. TELEPHONE NO. Springdale Fire Department FULL DEPARTMENT ADDRESS APPROVAL BY CHIEF OR TRAINING OFFICER PO Box 1521 Springdale AR 72765 SIGNATURE DATE TITLE Battalion Chief Training Officer I CERTIFY THAT THE INFORMATION RECORDED ON THIS APPLICATION IS CORRECT. FALSIFICATION OF INFORMATION MAY RESULT IN DENIAL OF ADMISSION* BY SIGNING THIS APPLICATION THE STUDENT AGREES TO ALLOW THE ACADEMY TO MAIL THE CERTIFICATE TO HIS/HER DEPARTMENT. AFTER THAT TIME THE RELEASE OF INFORMATION ABOUT COMPLETION OF THIS COURSE AND CREDIT FOR IT WILL BE MADE ONLY UPON SIGNED PERMISSION BY THE STUDENT.

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