Print this form, fill out, enclose a check payable to FIRETAC, INC., and mail to:
WVU Fire Service Extension
P.O. Box 6610
Morgantown, WV 26506-6610
| NAME | BIRTH DATE |
| SS# | |
| HOME ADDRESS | |
| CITY, ST, ZIP | DAYTIME PHONE |
| DEPARTMENT | |
| ADDRESS | |
| CITY, ST, ZIP | |
SS# and Birth Date Required
Please register me for the following classes:
1.
2.
3.
4.
In the event the classes I register for are full or closed, please register me for the following classes:
1.
2.
3.
4.
| REGISTRATION FEES: (if paid by June 30, 2002): | ||
| Fire Department Fee: $60 | Industrial Fee: $150 | |
| FIRETAC MEMBER REDUCED FEES | ||
| Fire Department Fee: $50 | Industrial Fee: $100 | |
| TOTAL ENCLOSED | $ | |
