Campus Fire Data - Register

Account Application for Fire Department Affiliation

Complete ONLY if you are affiliated with a Fire Department that would respond to a fire at a local University/College. If you are NOT affiliated with a Fire Department, click the browsers back button and choose UNIVERSITY/COLLEGE AFFILIATION

Registration Details
User Name:		User Name needs to contain a minimum of 5 characters. Only letters, numbers, and underscores are allowed.
Password:		Password needs to contain a minimum of 7 characters. Only letters and numbers.
Confirm Password:
Email:
Confirm Email:
First Name:
Last Name:
Job Title:
Fire Department Affiliation:		Enter name and address of the fire department you represent. You will be asked to list the local colleges in the area that you typically respond to at the end of this application.

Address 1:
Address 2:
City/Town:
State:
Zip:
Country:
URL:
Phone:
Local University/College you typically respond to:		List all the colleges or universities you respond to seperated by a comma.

Are you a member of the Center for Campus Fire Safety?	Yes No	If not, click to visit our site and learn more: www.campusfiresafety.org
Have you attended our free Firewise Campus Instructor Training?	Yes No	If not, click to visit our site and learn more: www.firewisecampus.org
Would you like to receive our free monthly newsletter, Campus Firezone?	Yes No	To receive future newsletters click: www.campusfiresafety.org and sign up to be included in our mailing list. To download previous issues visit: www.campusfiresafety.org/CFZ.html
Affilation Logo		Image must be a jpg file.
About Affilation

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