2. 
3. Training Request Form
   Required for all DFRS personnel
5. Employee Information
7. First Name*
8. Last Name*
10. Address1*
12. City*
13. State*
    -- Select One --MDPAWVVADE
14. Zip*
16. Date of Birth*
    Date of Birth
17. Phone Number*
18. Email Address*
20. Station/Shift*
21. EMT Expiration Date*
    EMT Expiration Date
25. Course Information - DFRS Academy
27. Academy Courses

    1. TB 22-031 Swiftwater Rescue Technician; Dates: 4/3, 4/7, 4/11, 4/13, 4/17, 4/20, 4/24, 4/27, 5/1, & 5/4; Location: Northgate Fire Station # 29
    2. TB 22-033 Instructor I (Pilot); Dates: 3/8, 3/14, 3/20, & 3/23; Location Northgate Fire Station # 29
    3. TB 22-034 Conducting Safe Live Fire Training Exercise; Dates 2/1/23 & 2/2/23; Location Northgate Fire Station #29
    4. TB 22-035 Strategy and Tactics for Initial Company Operations (NFA); Dates 3/2, 3/6, & 3/8; Location PSTF
31. Course Information - MFRI North Central & Western MD Regions
33. Fire Department Incident Safety Officer

    1. MGMT-217-S004-2023; Start Date 11-22-2022; End Date: 12-20-2022; Registration Close: 11-02-2022; Location: Howard County DFRS Training Academy
    2. N/A
35. Aerial Apparatus Driver/ Operator

    1. FIRE-114-S015-2023; Start Date: 3/19/23; End Date: 6/1/23; Registration Close: 2/28/23;Location: Washington County Public Safety Training Center
    2. N/A
37. Conducting Safe Live Fire Training Evolutions

    1. MGMT-215-S007-2023; Start Date 4/30/23; End Date: 5/7/23; Registration Close: 4/10/23; Location Washington County Public Safety Training Center
    2. N/A
39. Fire Department Incident Safety Officer

    1. MGMT-217-S011-2023; Start Date 1/22/23; End Date 2/12/23; Registration Close: 1/2/23; Location Washington County Public Safety Training Center
    2. MGMT-217-S004-2023; Start Date 1/24/23; End Date: 2/23/23; Registration Close 1/4/23; Location Howard County DFRS Training Academy
41. Fire Officer II (Piliot)

    1. MGMT-202-S009-2023; Start Date: 3/6/23; End Date: 6/19/23; Registration Close: 2/21/23; Washington County Public Safety Training Center
    2. N/A
45. Other Courses (not listed above)
47. Course Title
48. Course Number
49. Course Location
51. Start Date
    Start Date
52. Complete Date
    Complete Date
53. Deadline to Register
    Deadline to Register
55. PLEASE ATTACH INFORMATION (BROCHURE, NOTICE, ETC.) ABOUT THE COURSE.
56. Attachments
58. REFER TO DFRS POLICY 2.01.11 FOR REGISTRATION INFORMATION.
60. Cost of Class/Course

    Check all that apply

    1. Hotel
    2. Tuition
    3. Books (Non-MFRI)

    1. Air Fare
    2. Travel

    1. Per Diem
    2. Other
61. Itemized Cost
63. County Vehicle Request?

    1. Yes
    2. No
64. Pickup Date and Drop off Date
    Pickup Date and Drop off Date Start Date

    —

    Pickup Date and Drop off Date End Date
65. Estimate Vehicle Mileage
    (Estimate mileage) x (Current rate) = Travel Cost
67. Comments
71. Supervisors
73. Chiefs*

    If applicable, in addition to your Battalion Chief, also select Battalion Chief Mike Cole for ALS Training. For Special Ops, also select Lenne Stolberg. IF REQUESTING A VEHICLE OR IF THERE IS A FEE ASSOCIATED WITH THIS TRAINING, ALSO SELECT THE BATTALION CHIEF OF TRAINING.

    1. Barnes, David
    2. Bailey, Andre
    3. Cave, Chad
    4. Coe, Tom
    5. Cole, Mike
    6. Dmuchowski, Mike

    1. Grossnickle, Troy
    2. Hahn, Rusty
    3. Healy, Dan
    4. Leatherman, Steve
    5. Malta, Francis
    6. Mullendore, Christopher

    1. Newman, Jon
    2. Poole, Kenneth
    3. Scott, Charles
    4. Stolberg, Lenne
    5. Wade, Jeremy
    6. Wallick, Doug
75. Captains & Lieutenants

    Captains & Lieutenants will receive immediate notification of training request.

    1. Ahalt, Bill
    2. Arnold, John
    3. Austin, Thomas
    4. Baer, Richie
    5. Bauer, Eric
    6. Bare, Craig
    7. Bennett, Donnie
    8. Brown, Jared
    9. Burke, Edward
    10. Chlebowski, Josef
    11. Coe, David
    12. Coe, Jordan
    13. Creager, Kevin
    14. Davis, James
    15. Day, Alan
    16. Dimopoulos, Christopher
    17. Dickinson, Jason
    18. Dishart, Joshua
    19. Donovan, Sean
    20. Dunn, Christopher
    21. Elliott, Harry
    22. Fisher, James

    1. Freeman, Robert
    2. Gordon, Scott
    3. Goforth, Kevin
    4. Green, Charlie
    5. Haddad, Jonathan
    6. Hardin, Daniel
    7. Hardin, Douglas
    8. Harne, Jacob
    9. Harner, Tyler
    10. Hayter, Daniel
    11. Hubble, Keith
    12. Hubler, David
    13. Hudson, Kenneth
    14. Johnikin, Anne
    15. Johnson, Matthew
    16. Jones, Stephen
    17. Karas, Matthew
    18. Kessler, Larry
    19. King, Patrick
    20. Knight, Matthew
    21. Knight, Michael
    22. Komykoski, Jason

    1. Lal, David
    2. Lane, George
    3. Leonard, Michael
    4. Lewis, Steven
    5. Love, Vernon
    6. McCaa, Robert
    7. McKittrick, Jesse
    8. McTighe Jr., Patrick
    9. Miller, Matthew
    10. Moravec, Steven
    11. Nye, Matthew
    12. Osele, Michael
    13. Parr, Joel
    14. Peterson, Jeremy
    15. Pressman, Cameron
    16. Richman, Jeffrey
    17. Rossomondo, William
    18. Ruch, Glenn
    19. Russell, Troy
    20. Schultz, Steve
    21. Shaw, Matthew
    22. Shelton, Timothy

    1. Sherman, Tyler
    2. Springirth, Jesse
    3. Stansbury, Matthew
    4. Staub, Bradley
    5. Steele, Michael
    6. Steinberg, Adam
    7. Stitely, Richard
    8. Strausbaugh, Kyle
    9. Studds, Bernard
    10. Stull, Jeffrey
    11. Trevey, Kevin
    12. Tucker, Clarence
    13. Veith, William
    14. Walter, Joshua
    15. Weaver, Jeremy
    16. Webb, Michael
    17. Welsh, Larrie
    18. Wilby, Matthew
    19. Wiles, Matthew
    20. Winters, Daniel
    21. Yingling, David
77. I agree to submit to DFRS documentation regarding my successful completion of this course. I further agree to abide by the Travel Regulations and Expense Report procedures detailed in Section IV of the Frederick County Purchasing Rules & Regulations, if applicable.*

    1. Checking box is equivalent to my electronic signature.
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit Submit and Print

* indicates a required field