MORRIS COUNTY PUBLIC SAFETY TRAINING ACADEMY
P.O. BOX 900 MORRISTOWN, NEW JERSEY 07963-0900
(973) 285-2979 - FAX (973) 285-2971
Academy is located at 500 West Hanover Avenue - Parsippany
FIRE DIVISION ON-LINE REGISTRATION FORM
* = Required Field

*Course Title:			Course #: (for FF 1, FF 2, & Junior Courses)
*Course Date:			*Tuition:
NOTE:	If a pre-requisite is required for this course, documentation of successful completion (certificate) must accompany registration if not conducted by our staff at Morris County Public Safety Training Academy. Registrations WILL NOT be processed without required documentation.
*NAME		*SOCIAL SECURITY NO. Choose one. If printing form, use blank.		*HOME PHONE NO.
1.		Already on file at Academy Not on file; will bring to class
2.		Already on file at Academy Not on file; will bring to class
3.		Already on file at Academy Not on file; will bring to class
4.		Already on file at Academy Not on file; will bring to class
5.		Already on file at Academy Not on file; will bring to class
6.		Already on file at Academy Not on file; will bring to class
Separate forms are required for each course.
CERTIFICATIONS:           I hereby certify the above listed personnel are covered by Workmen's Compensation and Liability Insurance or otherwise adequately insured. The Academy requires a certificate of insurance from every sending department. Certificates are to updated yearly. Certificates of Insurance requested by the County of Morris must contain the following language: "THE COUNTY OF MORRIS IS AN ADDITIONAL INSURED."           I further certify that any student participating in live fire or S.C. B.A. training has completed the OSHA Respiratory exam and is certified medically fit to wear S.C.B.A.            To the fullest extent permitted by law, the municipality, or agency requesting training for this individual, agrees to defend, indemnify and hold harmless the County of Morris, the Morris County Public Safety Training Academy, and all employees, servants and agents ("the County") from any liability, claims, civil actions, and expenses (including reasonable attorneys' fees) arising out of the training or instruction to be provided at the Academy. Said agreement shall apply, regardless of the allegations made against the County by the officer, this organization, or a third party.

*PRINT NAME OF CHIEF OR AUTHORIZED OFFICIAL:		E-MAIL:
*DEPARTMENT:		*PHONE:
*MAILTO ADDRESS:		FAX:
*TOWN/ZIP:
*SIGNATURE OF CHIEF OR AUTHORIZED OFFICIAL: