TENNESSEE FIRE SERVICE AND CODES ENFORCEMENT ACADEMY

TENNESSEE FIRE SERVICE AND CODES ENFORCEMENT ACADEMY

Tennessee Fire Service and Codes Enforcement Academy
2161 Unionville/Deason Road
Bell Buckle, TN 37020
Phone (931) 294-4111
Fax (931) 294-4121

REGISTRATION FORM

Please fill out completely unless instructed otherwise.

SECTION 1 -GENERAL INFORMATION

Name	First MI Last
Street Address
City	State Zip Code
Email Address (Required)
Phone # (Numbers Only)	Home Work
	SSN# (Last 4 DIGITS ONLY)
In Case Of Emergency Contact	Name Phone #
Agency/Organization/Business that you Represent	Organization Name
Agency/Organization/Corporation Tax Exemption Number	Number
Agency/Organization/Business Address	Organization Address ZIP Code Fire Dept. ID: (If applicable)
Please Check	Municipal Fire Department Career Vol. Combination County / Other Fire Department Career Vol. Combination Municipal Codes Department County Codes Department Municipal Codes Department Private Industry State Govnt. Federal Govnt. Other
Check the number that reflects the highest level of your formal education	High School 9 10 11 12 GED College 1 2 3 4 Graduate School 1 2 3 4 5
Gender: Male Female	Any Physical Impairement: Yes No If yes, please note accomodations request in the comment section below (above signature).

SECTION 2 - COURSE REGISTRATION (All courses require a minimum number of students)

Course Number: Course Title Course Date: Course Fee:

Have you attended TFACA or TN Fire School classes previously ? Yes No Approximate Date last Course Taken

Are you a US Citizen? Yes No If not US Citizen, where were you born ?

TN Code Inspector Certification # (If applicable): Fire Building Tennessee Resident: Yes No

Comments:

By Checking the box below, I Certify that the information recorded on this application is correct. I agree to abide by the rules and regulations of Tennessee Fire Service and Codes Enforcement Academy. If i am adminited as a student, falsification of information may result in denial of course attendance or a course certificate. I hereby authorize the release of any and all information concerning my enrollment in this course to my sponsoring agency. Further, I understand that the State of Tennessee / TFACA does not provide insurance for students and does not accept responsibility for injuries incurred at the Academy.

Your Full Name: Date:

ACCOMMODATIONS
DORMITORY AND MEAL INFORMATION

INDIVIDUAL STUDENT ACCOMMODATIONS

Course Name: Start Date:

Student's Full Name:

Dormitory Accommodation needed (Required Field): Yes No

Arrival Date: (Student check-in 16:00 -21:00)

Departure Date: (Student check-out Time: 08:00)

Total Length of Stay: Days / Nights (i.e., 5 Days /4 Nights)

INDIVIDUAL STUDENT ACCOMMODATIONS

Name Of Group / Fire Department / Organization:

Group Contact Name: Group Contact Phone:

How many in Group / Fire Department / Organization:

Number of rooms required:

Number of Male Occupants: Female:

Number of handicapped Accessible rooms required:

Total Length of Stay: Days / Nights (i.e., 5 Days /4 Nights)

If you have any questions regarding accommodations, please contact Kerry Kimmel,
Hospitality Manager @ (931) 294-4305