Name* First Last Address* 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 PhoneCell PhoneEmail* What classification of Instructor are you?* State only State/Staff Instructor Specialty / Instructor Emeritus State Instructor maintenanceInstructions:To maintain the your status as a State Fire Instructor you must meet what is outlined in Fire 404.04 State Instructor: Maintenance status. At minimum you must have taught a minimum of 3 courses in a 12-month period or have participated in a commission-approved continuing education program. At this time the continuing education program consist of taking 6 hours of continuing education. You are not required to complete both sections, fulfilling the requirements of one section will complete the requirements.Type of renewal* Instructional Activity Continuing Education Instructional Activity*Please list out the course DATES, TOPIC, and CREF numbers of the courses. You must list out a minimum of 3 courses in which you taught.DateLocationTopicCREF Continuing Education*Please list out the course DATES, TOPIC, and CREF numbers of the courses. There must be a minimum of 6 hours. Click the plus sign at the end of the first line to add additional lines.DateLocationTopicCREF I certify that the above information is correct and true to the best of my knowledge.* I Agree I DO NOT Agree Staff/Specialty Instructor acknowledgementsI have read and understand the Division's policy on the Instructor Code of Professionalism.*Instructor Code of Professionalism I Agree I Disagree I have read and understand the Division's Human Dignity Statement.*Human Dignity Statement I Agree I Disagree