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FDSOA-Logo-FullColor_RGBAt72ppi-300x300AFFIDAVIT FOR INCIDENT SAFETY OFFICER SKILLS VALIDATION

Fire Department Safety Officers Association
33365 Raphael Rd, Farmington Hills, MI 48336  •   fdsoa@fdsoa.org

APPLICANT’S INFORMATION (Please Type or Print All Information)

Name: _____________________________________________ SS# Last 4 digits: _______________

Agency:____________________________________________ Rank: _________________________

Mailing Address:________________________________________________

City: ______________________________________ State: _______ Zip: ________________

Day Phone: _____________________ Email: _____________________________________________

Dates of attendance at class if applicable: _________________________________________________

Here are your Six (6) Randomly selected and assigned Skill Sheets. Reminder, you can find all the skill sheets on the FDSOA web site on ISO Certification page . Signed affidavit must be received by the FDSOA office within one (1) year of taking the test.

1, 4, 7, 12, 13, 19

Applicant’s Validation Statement

I verify that I have completed the requisite skill sheets provided by the FDSOA for ISO certification. I am only required to return this affidavit but I understand that the FDSOA may conduct random audits and request completed sheets.

Candidate’s signature____________________________________________ Date______________

Skills Validation Statement by Employer (Required)

I verify that I am a Chief Officer for the above applicant’s agency and the said applicant has completed requisite skills sheets developed by the FDSOA as written in NFPA1521, Standard for Fire Department Safety Officer Professional Qualifications (2015):

Print Name: _______________________________________ Title: _______________________

Signature: ________________________________________ Date: _______________________