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State of New York Firefighting and Code Enforcement Personnel Standards and Education Commission RETURN TO: Standards Unit NYS DHSES Office of Fire Prevention and Control 99 Washington Ave, Suite 500 Albany, NY 12201-2833 (518) 474-6746 HOME ADDRESS (STREET, PO BOX) CITY STATE ZIP STUDENT TRAINING ID NUMBER NIGHTTIME PHONE NAME (LAST, FIRST, MI) PLEASE PRINT OR TYPE DAYTIME PHONE DATE OF BIRTH DATE OF APPLICATION FIRE DEPARTMENT CODE ( ) ( ) DATE OF APPOINTMENT FIRE DEPARTMENT NAME Additional copies of this application are available on the web at www.dhses.ny.gov/ofpc/training/fire-academy/certifications.cfm o be completed by fire chief, fire commissioner or top ranking municipal official. I, do hereby designate the above applicant as a Fire Investigator Level II and certify thathe/shehascompletedaminimumof50hoursoffireinvestigationactivities. Iherebycertifytheabovestatement is true and accurate to the best of my knowledge. 900 (Rev. 2/13) Fire Investigator Level II - Application Fire Investigator Level I Certification Number Completion date of New York State course: Date Instructor Name Fire/Arson Investigation (1300) (80 hours) Note: For equivalent course material in lieu of New York State courses, adequate documentation of course content, hours and completion must be submitted for review to the State Fire Administrator. I, do hereby request certification for Fire Investigator Level II under Part 426.8 of the Minimum Standards for Firefighting Personnel in the State of New York. I certify that I have completed 80 hours of required New York State course material and performed 50 hours* of fire investigation activity. I hereby certify the above statement is true and accurate to the best of my knowledge. print print E T A D E R U T A N G I S E T A D E R U T A N G I S RANK OR TITLE NAME OF FIRE DEPARTMENT OR MUNICIPALITY To facilitate your application, please include copies of any certificates for courses taken within the last six months. RETURN TO: Standards Unit NYS DHSES Office of Fire Prevention and Control 1220 Washington Avenue Building 7A, Floor 2 Albany NY 12226 (518) 474-6746 N Y ---PAGE BREAK--- Fire Investigator Level II- Case Listing Please document the cases where Fire Investigation activity was performed by the applicant. *This activity must be performed after completing the Fire/Arson Investigation (1300) training course. A maximum of 10 hours per investigation shall be credited toward the completion of the 50 hour investigation hour requirement. CASE NAME / NUMBER or INCIDENT ADDRESS INITIAL RESPONSE AGENCY NAME or FDID DATE ACTIVITY STARTED HOURS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 PLEASE PRINT