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2. Your Name*
3. date
   date

   date
4. Class title*
6. Course date(s)*
7. Instruction Method*

   1. Drill
   2. Lecture
   3. Self-Study
   4. Computer Based
8. Total Hours*
10. Class Description
11. Instructor*
13. Location*

    1. Training Center
    2. Fire District
    3. Hospital
    4. Out of City
14. Shift

    1. A shift
    2. B shift
    3. C shift
    4. Other
15. Training Type*

    1. Fire
    2. Rescue
    3. Medical
    4. Other
17. A Platoon

    1. Thompson, Eddie
    2. Hoyer, Jeremy
    3. Carrillo, Omar
    4. Kirts, Josh
    5. Harp, Travis
    6. Holmes, Trintin
    7. Hayden, Richard
    8. Bray, Austin
    9. Cerasale, Mike
    10. Rogers, Shawn
    11. Elington, Adam
    12. Keck, Nathan
    13. Fuller, Keith
    14. Hewlett, Lacie
    15. McDonald, Stephen
    16. Mason, Scot
    17. Reaves, Rick
    18. Shelley, Tyrell
    19. Box, Aaron
    20. Fox, John
    21. Clymer, Levi
    22. Doyle, Colton
    23. Frederking, Adam
    24. Hellard, Bill
    25. Steele, Tyler
    26. Meeker, Andy
    27. Osbourn, Blake
    28. Emerson, Ramsey
    29. Miller, Matt
    30. Dake, Cheyne
    31. Hunt, Kyle
    32. Terrell, Josh
    33. Barnes, Jeremy
    34. Kincy, Eric
    35. Ponthieux, Jonathon
    36. Ballou, Blake
18. B Platoon

    1. Meredith, Dusty
    2. Qualls, Dusty
    3. Slyter, Jackie
    4. Jones, Al
    5. Conroy, Matt
    6. Tedford, Kyle
    7. Martin, Eric
    8. Cawthon, Connor
    9. Bobholz, John
    10. Lundberg, Colt
    11. Whitlow, Alan
    12. Chapman, Josh
    13. Copeland, James
    14. Wassman, Jack
    15. Bingham, Bryan
    16. Bayer, Brandon
    17. Chapell, Kevin
    18. Ardemagni, Nick
    19. Hulsey, Wade
    20. Brightwell, Kevin
    21. Pasquale, Peter
    22. Howard, Brandon
    23. Sutherlan, Chase
    24. Williams, David
    25. Bevis, Brian
    26. Villines, Jason
    27. Welch, Brandon
    28. Braswell, Mike
    29. Earp, Doug
    30. Rosales, Santiago
    31. Melnicki, Pete
    32. Schube, Doug
    33. Whittington, Josh
    34. Tibbs, Kevin
    35. Chandler, Troy
19. C Platoon

    1. Whitlow, David
    2. Bray, Greg
    3. Meeks, Nathan
    4. Tucker, Jacob
    5. Aresco, Anthony
    6. Crump, Kari
    7. Burnett, Zach
    8. Nance, Jonathan
    9. Neitzel, Damion
    10. Dean, Michael
    11. Clark, Cleve
    12. Ireland, Cheyenne
    13. Bowen, Clint
    14. Parks, Jeff
    15. Loyer, Lance
    16. Miller, Patrick
    17. Elliott, Frankie
    18. Taylor, Robert
    19. Jordan, Kyle
    20. Leatherman, Daniel
    21. Crisp, Randy
    22. Treat, Shawn
    23. Starek, Rob
    24. Pace, Nicholas
    25. Oldebeken, Zachary
    26. Gripe, Cody
    27. Wassman, Jeff
    28. Dunavan, Josh
    29. Bliss, Scott
    30. Huntington, Bill
    31. Lehman, Zac
    32. Mendham, Scott
    33. Sampier, Rob
    34. Roten, Nathan
21. Additional crew
    enter any members not listed elsewhere
22. Notes
23. Acknowledgement*

    1. Agree

    I confirm that the candidate/s listed have received training in the skills/knowledge and have proficiently demonstrated all competencies specific to course listed. I certify that all information is accurate and to the best of my knowledge all students indicated were present for this training.
25. Attachments
    Attach any documentation if applicable.
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28. Email address

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