"*" indicates required fields Step 1 of 9 11% Personal DemographicsName* First Middle Last Do you work for the Department of Safety*NoYesYour Division/Bureau*FST&EMSEmergency Services and CommunicationsFire SafetyBureau of HearingsGrants ManagementHSEMState PoliceDMVAdministrationAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your best contact phone number*Your best contact Email* Please select the resources that you would like to request* Classroom/Facility/Dorm Room Audio/Visual Equipment Vehicle Request Fire/EMS Course Prop Reservation Vehicle RequestProgram NameReason for travel*Destination city/town*Start Date* MM slash DD slash YYYY End Date* MM slash DD slash YYYY Start Time* Hours : Minutes AM PM AM/PM End Time* Hours : Minutes AM PM AM/PM Vehicle InformationPlease select from the following:* Utility 3 - GMC 2500 Utility 5 - Freightliner S602 - Impala S607 Transit S608 - Silverado S619 - Dodge Caravan S620 - Dodge Caravan Black Landscape Trailer Red Landscape Trailer Orange Flatbed (5th wheel) Red Flatbed (5th wheel) Facility ReservationStart date that classroom or dormroom is needed* MM slash DD slash YYYY End date that classroom or dormroom is needed* MM slash DD slash YYYY Start time of event* Hours : Minutes AM PM AM/PM End time of event* Hours : Minutes AM PM AM/PM Are you requesting a CLASSROOM for an activity or a DORM room to stay in?* Classroom or auditorium Dormitory room NO REQUESTS WILL BE APPROVED MORE THAN 60 DAYS PRIOR TO THE DATE OF THE ACTIVITY.Requesting Organization*Number of attendees*Address of requesting organization* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact person* First Last Position or title of contact person*Activity description (how does this relate to the emergency medical or fire service, MUST be completed for consideration* Facility reservation continuedAre you charging for this activity? YES NO Are you requesting to use a caterer at our facility? YES NO Once confirmed, please arrive early to the Fire Academy to ensure the classroom is setup in the style you prefer. At this time groups are responsible for configuring the classroom and rearranging it at the completion of the utilization.This field is hidden when viewing the formClassroom set up: POD style Box style U Shaped style Classroom style Select from the followingAuditoriumAuditorium Half dayAuditorium Full dayAuditoriumAuditorium Half dayAuditorium Full daySingle classroomClassroom 1 half dayClassroom 1 full dayClassroom 2 half dayClassroom 2 full dayClassroom 4 half dayClassroom 4 full dayClassroom 5 half dayClassroom 5 full dayClassroom 6 half dayClassroom 6 full dayClassroom 7 half dayClassroom 7 full dayARFF Classroom half dayARFF Classroom full dayNorth Country Training Facility Classroom half dayNorth Country Training Facility Classroom full dayNorth Country Drill Yard Half DayNorth Country Drill Yard Full DayNorth Country A Building Half DayNorth Country A Building Full DayNorth Country Whhite House Half DayNorth Country White House Full DaySingle classroomClassroom 1 half dayClassroom 1 full dayClassroom 2 half dayClassroom 2 full dayClassroom 4 half dayClassroom 4 full dayClassroom 5 half dayClassroom 5 full dayClassroom 6 half dayClassroom 6 full dayClassroom 7 half dayClassroom 7 full dayARFF Classroom half dayARFF Classroom full dayNorth Country Training Facility Classroom half dayNorth Country Training Facility Classroom full dayNorth Country Drill Yard Half DayNorth Country Drill Yard Full DayNorth Country A Building Half DayNorth Country A Building Full DayNorth Country Whhite House Half DayNorth Country White House Full DayDouble classroomDouble Classroom Half dayDouble Classroom Full dayDouble classroomDouble Classroom Half dayDouble Classroom Full dayPlease select the classrooms you would like as part of the double classroom option: Classroom 1 Classroom 2 Classroom 4 Classroom 5 Classroom 6 Classroom 7 ARFF Classroom North Country Training Facility Classroom Do you need a conference call line? Yes No This is for the Division of FST&EMS only, if you need the conference phone please include an AV requestWill your event be held after business hours (before 8:00am or after 4:30pm or weekends)? Select one YES NO Please indicate the number of hours that your event will last in order to have facility staff on site and available (after normal business hours)After Hours 1 hourAfter Hours 2 hoursAfter Hours 3 hoursAfter Hours 4 hoursAfter Hours 5 hoursAfter Hours 6 hoursAfter Hours 7 hoursAfter Hours 8 hoursTotal Dormitory Room ReservationEmergency Contact Person* First Last Emergency contact person phone*How many nights will you be staying?1 night2 nights3 nights4 nights5 nights6 nights7 nights8 nights9 nights10 nightsDormitory payment formCopy and paste the URL link below into your web browser in order to download the dormitory payment form. Complete the form then attach it using the upload link below in order to send it with your online submission. This field is hidden when viewing the formUpload your payment page form here to send with your submissionAccepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 256 MB.Total Audio Visual RequestStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM I will need the following AV equipment: Computer and Projector in Classroom Conference Phone Portable Projector Screen Portable AV Kit for a Field Program Video Camera Digital Still Camera It is recommended that you bring your presentation with you on a flash drive and use the provided podium computer. Your laptop or other device may not work properly with the academy system and you may not be able to display your presentation directly from your laptop depending on its age or style/type.The conference phone will be delivered to the classroom and it is your responsibility to set the phone up and connect it to the network. The ED TECH group is not versed or responsible for conference phone connections.You will be required to pick up the portable AV kit from the ED TECH office at the Fire Academy. A team member will open and review the kit contents with you to ensure that it is working properly. You will be responsible for the kit condition and its contents while it is in your possession. If something becomes broken you will be asked to place an out of service tag on the kit.All persons who are requesting the use of our video cameras MUST be versed in their use. You will be responsible for filming your presentation or project as ED TECH personal are not included with the camera request to film. You will be responsible for the camera kit and its contents and condition while it is in your possession.I will need access to the Academy's wireless network. YES NO In order to access the wireless network you will need a one day access code pass and enter that information into the login screen when you open your internet browser on the day of your event. This pass can be obtained from the front reception desk when you arrive. Fire Prop ReservationName of Requesting Agency or Department Affilication*Name of training siteTraining site address where class will be held Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Contact InformationContact person for prop delivery First Last AFTER HOURS contact phone number Date of first training session MM slash DD slash YYYY Start time Hours : Minutes AM PM AM/PM End time Hours : Minutes AM PM AM/PM Is there a 2nd training date and time? YES NO Date of second training session MM slash DD slash YYYY Start time Hours : Minutes AM PM AM/PM End time Hours : Minutes AM PM AM/PM Is there a 3rd training date and time? YES NO Date of third training session MM slash DD slash YYYY Start time Hours : Minutes AM PM AM/PM End time Hours : Minutes AM PM AM/PM Props and EquipmentPlease select from the following: ADULT CPR Manikins (4 pack) INFANT CPR Manikins (4 pack) Air Trailer 1 Air Trailer 2 American Red Cross AED Trainers Confined Space Props Defibtech AED Trainers Engine 1 Engine 2 Extinguisher Prop HAZMAT Awaerness Operations Trailer HAZMAT Tech Trailer HAZMAT Decon Trailer IAFF Fireground Safety Props (CREF classes only) Ladder 1 Laerdal AED Trainers Multi force door prop North Country Training Facility- A Building North Country Training Facility- Drillyard North Country Training Facility- White House NHFA Drillyard - ARFF Drill Yard NHFA Drillyard NHFA Drillyard - A Building NHFA Drillyard - Auto Extrication NHFA Drillyard - B Building NHFA Drillyard - Flashover NHFA Drillyard - Lifting and Jacking NHFA Drillyard - LP NHFA Drillyard - Vent Prop NHFA Drillyard - Firehouse NHFA Drillyard - J Building Phillips AED Trainers Rescue 1 SCBA Trailer Trench Rescue Props Zoll AED Trainers Additional Notes (please list numbers of manikins or AED trainers neededCAPTCHA