P. O. Box 3063, SHERMAN, TX 75091  Phone: 903-564-3862. Fax: 903-564-3017

HAZ-CO FIRE TRAINING ACADEMY- Bill Palya, Coordinator
email:hazco@gotsky.com                                                                                     www.hazco-fire.com                            STUDENT APPLICATION

                Choose:  DAY CLASS or NIGHT CLASS  (PLEASE CIRCLE ONE)


                NAME__________________________________________D.O.B.________________AGE________
                                Last                First                M.I.

                SOC.SEC.#_______________________________________SEX  (CIRCLE ONE)  MALE  FEMALE

                HEIGHT___________WEIGHT___________HOME PHONE_______________________________

                                                                                                              (AREA CODE)
                HOME ADDRESS_______________________CITY____________ST_______ZIP_____________

                CURRENT EMPLOYER____________________________WORK PHONE__________________

                CELL PHONE:___________________EMAIL ADDRESS:_______________________________

                EDUCATION: CIRCLE THE HIGHEST LEVEL ACHIEVED


                        A. G.E.D.                                                              D. COLLEGE-BA
                        B. HIGH SCHOOL                                                 E. COLLEGE-MASTER
                        C. COLLEGE-ASSOC.                                            F. COLLEGE-DOCTORATE


                HAVE YOU HAD ANY FIRE TRAINING BEFORE?  EXPLAIN

                __________________________________________________________________________________

                DO YOU HAVE A CURRENT AMERICAN HEART ASSOCIATION CARD?_____________________

                WHERE DID YOU HEAR ABOUT HAZ-CO FIRE ACADEMY?______________________________

                HAVE YOU APPLIED TO OTHER FIRE ACADEMIES?              (CIRCLE ONE)   YES    NO

                IF YES, WHERE?__________________________________________________________________

                BY THE FIRST DAY OF CLASS, YOU MUST PROVIDE US WITH A COPY OF A MEDICAL PHYSICAL
               AND PULMONARY TEST.


                        ALL TUITION IS DUE BY THE FIRST DAY OF REGISTRATION.

        CLASS IS LIMITED TO 25 STUDENTS.  A DEPOSIT OF $500.00 PRIOR TO REGISTRATION WILL SECURE ONE
        OF THE FIRST 25 SPOTS.  ALL OTHERS WILL BE FIRST COME, FIRST SERVE.

        SIGNATURE OF APPLICANT  ______________________________________              DATE  ____________________

        T shirt size:   S   M   L   XL   2XL  (circle one)