AFFIDAVIT FOR INCIDENT SAFETY OFFICER SKILLS VALIDATION Fire Department Safety Officers Association 33365 Raphael Rd, Farmington Hills, MI 48336 •
[email protected] 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_________________________________________________ The 6 Skill sheets that I have completed are: _________________ _________________ __________________ __________________ __________________ __________________ 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: ___________________
