National Interagency Prescribed Fire Training Center

FY09 Workshop Application

April 5 thru April 11, 2009

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Position Title:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Series/Grade:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Region: \_\_\_\_\_\_\_Agency (i.e. FS, FWS, etc):
\_\_\_\_\_\_\_\_\_\_\_\_Other (i.e. State, Private):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Unit (National Forest or Refuge):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Subunit:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Business Mailing Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street Address (for Fedex):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Business
Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Cell Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Fax Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Home Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Supervisor's Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Supervisor's Mailing Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Supervisor's Email Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Prescribed Fire Qualifications: (Check highest current qualifications)
Prescribed fire experience:

\_\_\_RXB1 \_\_\_RXB2 \_\_\_RXI1 \_\_\_RXI2 Others: \_\_\_\_\_
\_\_\_\_\_ \_\_\_\_\_ years\_\_\_\_ or seasons\_\_\_\_

Check courses completed: \_\_\_\_\_S190 \_\_\_\_\_S290 \_\_\_\_\_S390
\_\_\_\_\_S490

Wildfire Qualifications (Include copy of most recent IQCS
printout):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If not red-carded, indicate dates the following training was completed:

PSM416 (Standards for Survival) \_\_\_\_\_\_\_\_\_\_\_\_\_*Using Your
Fire Shelter* video (NFES-1568)\_\_\_\_\_\_\_\_\_\_\_\_\_

**ARRIVAL/DEPARTURE:** Selected participants should plan to arrive by
1900 on Sunday, April 5^th^ and should plan to travel home on Sunday,
April 12^th^.

##### 

##### TO APPLY: Mail, fax or email a completed National Interagency Prescribed Fire Training Application Form and a copy of your red card or fire qualifications (if applicable) to:

##### Lil Dyck

##### The National Interagency Prescribed Fire Training Center

3250 Capital Circle SW, Tallahassee, FL 32310

### Fax: 850/523-8640 Phone: 850/523-8635 Email: [ldyck@fs.fed.us](mailto:cdetwiler@fs.fed.us)

##### Direct all questions to Jim Durrwachter, Director at 850/523-8633

**or**

Greg Seamon, Fire Training Specialist at 850/523-8631

**Application deadline for FY 2009 Workshop is [October 15,
2008]{.underline}**

*(We recommend that you follow up to assure your application has been
received and is complete.)*

***Selection Notifications will be mailed by October 17, 2008***