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									              OFFICER INSTRUCTOR QUALIFICATION PROGRAM
                Application Submittal Checklist (this should be first page)
You must submit your application in the order and as described below with tabs labeled as indicated. Any
deviation from this format will result in denial of your application and it will have to be resubmitted! Each
sheet in this workbook is a section and should be tabbed out and information requested placed in that
section only. This page and the next is a summary of the tabbed sections needed and should be placed at
the front. Be sure to fill out and print all worksheets to include as the front page of a section.

Fill in only the shaded orange areas, the totals will calculate automatically. Enter all questions that ask for
number of years in decimal format, i.e. '6 months' would be '.5'.

  Table of Contents
   ##      Include this page and the next at the front of the application binder

  Application Section I

   ##      Candidate Application Sheet

  Instructor Credentials Section II

   ##      The candidate must be certified a minimum of two (2) years as a General Level II Instructor.
            Place a copy of your Instructor Certificate or Fire & Rescue Commission transcript in
           this section with the IFSAC seal and number clearly visible. Effective July 01, 2009.
           Instructor II Certification Date

  Officer Credentials Section III

   ##      To become a qualified instructor, the candidate must be certified a minimum of
           five (5) years as a Fire Officer at the level they are eligible for. Place a copy of
           your Officer Certificate(s) here with the IFSAC seal and number(s) clearly visible.
           Effective July 01, 2009.
           Certification Dates:
                   Fire Officer I:                       Fire Officer II:                Fire Officer III:
  Experience Points Section IV

   ##      Experience sheet                                         Total Points Claimed:
           (No one year of experience can be carried in more than one category)                              0.00
  Education Points Section V

   ##      Education sheet                                                 Total Points Claimed:
                                                                                                             0.00
  Professional Designation Points Section VI
   ##      NFA Executive Fire Officer or Chief Fire Officer Designee Points Claimed:
                                                                                                             0.00
                                                                     Total Points Claimed:
                                                                                                             0.00


        NC Fire and Rescue Commission Officer I-V Instructor Qualification Manual, 2nd Ed. September 2009
                                      Officer Instructor Qualification Application


   Reference Section VII
   ##      Reference sheet with three references listed and three letters of reference
           from those listed in the reference section (one must be supervisor).
   Resume and Transcripts Section VIII
   ##      Resume included and is detailed enough in nature to provide accounting of years
           of experience being used for credit
   ##      Official transcript(s) included to verify education level being used for credit.

   STAFF USE ONLY

                       Total Points:               0.00
   Points Needed for Instructor Qualification:
   Fire Officer I                          30
   Fire Officer II                         50
   Fire Officer III                        70
   Fire Officer IV                         90




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 2
                                       Officer Instructor Qualification Application


                                             Application - Section I
   Name:
   Last:                                            First:                                           MI:
   Date of Birth:
        Month                          Day                      Year

   Social Security # (last 4 digits only):

   Current Mailing Address:
   City:                                           State:                   Zip:

   Email Address

   Prior Mailing Address:
   City:                                           State:                   Zip:

   Current Employer
   Job Title                                                             Years in Position
   Address

   Prior Employer                                                                     Years in position

   Have you ever been convicted of, pleaded no contest, prayer for judgment, or other similar
   judgments for a criminal misdemeanor, or felony? If yes, explain (Attach another sheet if needed).




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009         Pg. 3
                                    Officer Instructor Qualification Application


                                Instructor Credentials - Section II

Place a copy of your Instructor Certificate or Fire & Rescue Commission transcript in
this section with the IFSAC seal and number clearly visible. Effective July 01, 2009.




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 4
                                     Officer Instructor Qualification Application


                                  Officer Credentials - Section III
Check one (1) category below for which you have completed the requirements for certification.
The Review Board reserves the right to disallow any prior certification if it does not meet the
accepted standards in that field. (Officer Certification must be with the NC Fire and Rescue
Commission or equivalent). As stated above officer certification does not count toward points.
It is used solely for the purpose of determining the level at which you will be qualified to teach.

   ##     OFFICER I CERTIFICATION FROM AN ACCREDITED PROGRAM
          Certifying Agency
          Certification Date:

   ##     OFFICER II CERTIFICATION FROM AN ACCREDITED PROGRAM
          Certifying Agency
          Certification Date:

   ##     OFFICER III CERTIFICATION FROM AN ACCREDITED PROGRAM
          Certifying Agency
          Certification Date:

   ##     OFFICER IV CERTIFICATION FROM AN ACCREDITED PROGRAM
          Certifying Agency
          Certification Date:

   Attach your Officer Certificates following this page.




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009    Pg. 5
                                   Officer Instructor Qualification Application




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 6
                                     Officer Instructor Qualification Application


                                        Experience - Section IV
Use the descriptions provided for each position below to determine where to claim points for each
position held in a fire service organization. No one year of experience can be carried in more than
one category. For example if you serve as a Captain in a paid department and a Chief in a volunteer
department you can only count one of the positions for credit.
  Fire or Rescue Officer Years of Experience Documentation
   Multiply number of years served in officer position of a department by the factor for size of
   department.
   Company Officer                                                          Factor               Points
                      years at a 0 to 50 person department                    1.25      =
                      years at a 51 to 100 person department                  1.50      =
                      years at a 101 to 250 person department                 1.75      =
                      years at a 250 or higher person department              2.00      =
                                                                   Company Officer Total Points
   Battalion or Shift Chief                                                 Factor               Points
                      years at a 0 to 50 person department                    2.25      =
                      years at a 51 to 100 person department                  2.50      =
                      years at a 101 to 250 person department                 2.75      =
                      years at a 250 or higher person department              3.00      =
                                                         Battalion or Shift Chief Total Points
   Chief Officer                                                            Factor               Points
                      years at a 0 to 50 person department                    3.25      =
                      years at a 51 to 100 person department                  3.50      =
                      years at a 101 to 250 person department                 3.75      =
                      years at a 250 or higher person department              4.00      =
                                                         Battalion or Shift Chief Total Points

   Fire or Emergency Service Related Professionals Years of Experience
   Related Professional                                                     Factor               Points
                      years at a 0 to 50 person agency                        3.25      =
                      years at a 51 to 100 person agency                      3.50      =
                      years at a 101 to 250 person agency                     3.75      =
                      years at a 250 or higher person agency                  4.00      =

                                                           Related Professional Total Points


                                                           Total Experience Points:



NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009        Pg. 7
                                    Officer Instructor Qualification Application


                                        Education - Section V

Check only (1) of the following nine (9) levels of education. A list of fields considered to be related
the officer certification is contained in Appendix B of the Officer Instructor Qualification Manual.
Only degrees awarded by institutions that are accredited by the major accrediting bodies within
the United States shall be considered. The list of accrediting bodies can also be found in Appendix B.
Place a copy of your diploma for the education level you are claiming with this section.

   ##     High School Graduate, GED Certificate or Equivalent
                 10 Points

   ##     Associates Degree: Field unrelated to Officer qualification
                  15 Points

          Associates Degree: Field related to Officer qualification
                  20 Points

   ##     Bachelors Degree: Field unrelated to Officer qualification
                 25 Points

   ##     Bachelors Degree: Field related to Officer qualification
                 30 Points

   ##     Masters Degree: Field unrelated to Officer qualification
                 35 Points

   ##     Masters Degree: Field related to Officer qualification
                 40 Points

   ##     Doctorate Degree: Field unrelated to Officer qualification
                 45 Points

   ##     Doctorate Degree: Field related to Officer qualification
                 50 Points

                                                         Total Education Points:




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009        Pg. 8
                                    Officer Instructor Qualification Application


                           Professional Designations - Section VI

10 Point credit is available for recipients of either EFO or CFO professional designations




    #     Graduate of the National Fire Academy Executive Officer Program
               Date of Completion




    #     Current Designee Center for Public Safety Excellence Chief Officer
               Date of Completion

                                           Professional Designation Points




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 9
                                    Officer Instructor Qualification Application


                                       References - Section VII
     Include letters of reference from these three people listed in this section.
     At least one reference must be from a supervisor.

 1 Name
     Address
     City                                                               State         Zip
     E-mail                                                                         Phone
              Years Known                              Supervisor? (Y/N)


 2 Name
     Address
     City                                                               State         Zip
     E-mail                                                                         Phone
              Years Known                              Supervisor? (Y/N)


 3 Name
     Address
     City                                                               State         Zip
     E-mail                                                                         Phone
              Years Known                              Supervisor? (Y/N)




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 10
                                      Officer Instructor Qualification Application


                                Resume and Transcripts - Section VIII

Attach resume that is detailed enough in nature to provide accounting of years of experience being
used for credit.

Include official transcript(s) to verify education level being used for credit.




Additional Information:




NC Fire and Rescue Commission Officer Instructor Qualification Application, 2nd Ed. September 2009   Pg. 11

								
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