FPT STUDENT INFORMATION FORM

Fire Protection Technology STUDENT INFORMATION FORM

This information sheet is required of all Fire Protection Technology students and students that are interested in the Fire Protection Technology Program. This form must also be completed to request an appointment for advising and/or to request a tuition exemption form.

Before requesting a tuition waiver, please read the tuition exemption waiver policy information page.

Date:

First Name: Last Name:

Street Address:

City: State: Zipcode County:

Home Phone : Work Phone : Cell Phone :

Which number is the best to contact you? Home Work Cell

Are you currently an ACC student? Yes No

ACC Student ID #:

Email : If you are a current ACC student, please use your ACC Gmail address.

Fire Service Employment Information

Department

Station Assignment

Position

Do you currently have a degree? Yes No Some work towards

Name of college / institution

Degree

What are your career goals and expectations from this program?:

CHECK IF YOU ARE REQUESTING A TUITION EXEMPTION WAIVER & COMPLETE THE INFORMATION BELOW

*Have you read the Tuition Waiver Information Page? Yes No

*Have you been advised by the FIPR Dept. Chair? Yes No If yes, when?

*Have you faxed the required documentation? Yes No

*Have you converted your basic certification into college credit? Yes No

*If you answered no to any of the above steps, please complete those steps before submitting your request for a tuition exemption waiver.

Please list the term and the courses you are seeking a tuition exemption for:

Term:

Course(s)