DIVISION OF STATE FIRE MARSHAL
BUREAU OF FIRE STANDARDS AND TRAINING
TRAINING AFFIDAVIT
APPLICANT'S NAME___________________________________________________________________
DATE OF BIRTH _________________ SOCIAL SECURITY # _________________________________[1]
ADDRESS ___________________________________________________________________________
STREET CITY STATE ZIP
I _________________________________________, do hereby acknowledge that my
Application for Certification as a Firefighter(DI4-1016), submitted to the
Bureau of Fire Standards and Training on ______________________________
(date DI4-1016 was signed) cannot be executed because I have not completed
the Firefighter Training Program Minimum Standards Course) nor have I
successfully passed the State Examinations as required under 633.35 Florida
State Statutes.
_______________________________________
SIGNATURE OF APPLICANT
STATE OF FLORIDA
COUNTY OF ______________________________________
On _____________________, __________, _______________________________________ personally
(month and day) (year) (Applicant’s Name)
appeared before me and, __________ who is personally known to me, or __________ who has provided
_________________________________________________ as identification.
_______________________________________
Notary Public Signature
Commission expires: _____________________
PLEASE AFFIX SEAL ABOVE
DI4-1461 (FORMERLY FST-60) REVISED 01/01 MP
[1] Please note that the social security number is not required; however, if you provide it, it will greatly assist us in assisting you.