2. 
3. Instructor Interest Form
5. Employee Information
7. First Name*
8. Last Name*
9. State Provider ID#*
10. SSN (Last 5 Digits)*
12. Address1*
14. City*
15. State*
    -- Select One --MDPAWVVA
16. Zip*
18. Date of Birth*
    Date of Birth
19. Phone Number*
20. Email Address*
22. Station/Shift*
23. EMT Expiration Date
    EMT Expiration Date
24. CPR Expiration Date
    CPR Expiration Date
28. Instructor Interest
30. I am interested in becoming an instructor in the following discipline(s):

    CHECK ALL THAT APPLY

    1. Firefighter - Requires ProBoard Instructor I
    2. Rescue - Requires ProBoard Instructor I
    3. Emergency Medical Technician - Requires ProBoard Instructor I

    1. Community Outreach - CPR / First-Aid / Stop the Bleed
    2. Physical Fitness
    3. Other
34. Supervisors
36. Chiefs*

    If applicable, in addition to your Battalion Chief, also select Battalion Chief Mike Cole and Captain Kathleen Harne for ALS Training. For Special Ops, also select David Barnes. 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. Coe, Tom
    3. Cole, Mike
    4. Dmuchowski, Mike

    1. Grossnickle, Troy
    2. Hahn, Rusty
    3. Healy, Dan
    4. Leatherman, Steve

    1. Morgan, James
    2. Poole, Kenneth
    3. Stolberg, Lenne
    4. Wallick, Doug
38. Captains & Lieutenants

    Captains & Lieutenants will receive immediate notification of training request.

    1. Ahalt, Bill
    2. Austin, Thomas
    3. Baer, Richie
    4. Bailey, Andre'
    5. Bare, Craig
    6. Barrick, Jason
    7. Bennett, Donnie
    8. Brown, Jared
    9. Burke, Edward
    10. Carmack, Newman
    11. Cave, Chad
    12. Chlebowski, Josef
    13. Coe, David
    14. Coe, Jordan
    15. Creager, Kevin
    16. Davis, James
    17. Day, Alan
    18. Dimopoulos, Christopher
    19. Dickinson, Jason

    1. Donovan, Sean
    2. Elliott, Harry
    3. Fisher, James
    4. Freeman, Robert
    5. Gordon, Scott
    6. Goforth, Kevin
    7. Green, Charlie
    8. Hardin, Daniel
    9. Hardin, Douglas
    10. Harne, Kathleen
    11. Harner, Tyler
    12. Hayter, Daniel
    13. Hubble, Keith
    14. Hubler, David
    15. Jacobs, Eric
    16. Johnikin, Anne
    17. Kessler, Larry
    18. Komykoski, Jason
    19. Laird, Josh

    1. Lal, David
    2. Lane, George
    3. Leonard, Michael
    4. Lewis, Steven
    5. Malta, Frank
    6. McCaa, Robert
    7. McKittrick, Jesse
    8. McTighe Jr., Patrick
    9. Morlan, Christopher
    10. Mullendore, Chris
    11. Newman, Jon
    12. Nuse, Tom
    13. Osele, Michael
    14. Peterson, Jeremy
    15. Richman, Jeffrey
    16. William Rossomondo
    17. Schultz, Steve
    18. Schwab, Warren
    19. Scott, Charles

    1. Shaw, Matthew
    2. Shelton, Timothy
    3. Stansbury, Matthew
    4. Steele, Michael
    5. Stitely, Richard
    6. Strausbaugh, Kyle
    7. Veith, William
    8. Wachter, Vernon
    9. Wade, Jeremy
    10. Walter, Joshua
    11. Weaver, Jeremy
    12. Webb, Michael
    13. Welsh, Larrie
    14. Wilby, Matthew
    15. Wiles, Matthew
    16. Winters, Daniel
    17. Yingling, David
    18. Yoder, Daniel
40. 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.
42. Questions? Contact Lieutenant of Training - RMcCaa@FrederickCountyMD.gov
46. Comments
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