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IAFF: Wellness/Fitness Initiative

FGS License Application

1. Fire Department:


2. Fire Chief or Fire Administrator:
Name:
Title:
Address 1:
Address 2:
Address 3:
Telephone:
FAX:
E-mail:

Please send the FGS License to this individual at the address above.
Please send the FGS License to someone else.


3. Is your jurisdiction seeking to deliver the FGS program in full accordance with the terms and conditions set forth in the IAFF Fire Ground Survival Licensing Agreement?

Yes No

a. If yes, when will training begin:

4. - Terms
As a condition of receiving a Full License, an applicant must agree that it will conduct the IAFF Fire Ground Survival Program in accordance with the IAFF’s licensing requirements. The full licensee shall:

i.utilize only IAFF-Certified FGS Instructors (minimum of two) -- FGS Assistant Instructors are also permitted to be utilized by Full Licensees;

ii.build/purchase the required IAFF FGS equipment and props and verify that such equipment and props conform to all specifications in the IAFF FGS manual;

iii.ensure that it has the ability to administer the IAFF FGS Program in conformity with the specifications set forth with the FGS Program;

iv.ensure that each trainee has completed the IAFF FGS online Awareness Course; and

v.provide to the IAFF, on an annual basis, a roster of all individuals trained to the IAFF FGS Operations Level.

Please provide the following information for the required minimum of two IAFF certified FGS instructors:

IAFF certified FGS instructor 1
Name:
IAFF ID#:
Title:
Address 1:
Address 2:
Address 3:
Telephone:
E-mail:
IAFF certified FGS instructor 2
Name:
IAFF ID#:
Title:
Address 1:
Address 2:
Address 3:
Telephone:
E-mail:
5. Has your department received the IAFF approved FGS props?
Yes No

a. If yes, was the equipment purchased:
As a package through hosting an FGS Train-the-Trainer class
Purchased separately from Technical Training Props, Inc.
Wooden props built according to the specification in the IAFF FGS manual

Other



6. Will your organization deliver FGS Operations training, or will a different agency, consultant, fire academy, or college provide the training?
Our organization will deliver the training A different agency will deliver the training

a.If conducted internally or externally, will the FGS props be assembled in accordance with the guidelines included in the FGS manual?

Yes No

If completed externally, please provide the name and address of the organization:
Name:
Address 1:  
Address 2:  
Address 3:  
16. Pursuant to the IAFF FGS licensing agreement, licensees are required to provide an attendance roster of all personnel completing the IAFF FGS Operations Course to the IAFF on an annual basis.
Are you willing to provide this information for each participant to the IAFF on an annual basis?
Yes No

The IAFF does NOT grant a license for the creation of derivative works, or works that are based on whole or in portion of the FGS Program. This includes works that are written as well as oral. Specific, written permission is necessary from the IAFF in order to create derivative works. The copyright on the FGS program is registered with the United States Copyright Office and the IAFF reserves all rights and remedies for copyright infringement for any illegal use, distribution, copying or creation of derivative works that are not covered by this license.

By completing and submitting this application, the applicant agrees to only use the FGS Program in whole in complete accordance with the FGS Licensing agreement, and only for the purpose of training in fire ground survival. This includes, but is not necessarily limited to, proper program administration including using specified equipment and qualified instructors. FGS licenses are subject to termination at the election of the IAFF by written notice for any reason and a license cannot be transferred or sub-licensed to any third parties. Any attempt by the licensee to use the FGS program for any purpose not specifically stated in the licensing agreement is inconsistent with the scope of this license, and is therefore prohibited.


Name of individual who completed form:



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