Active Shooter and Medical Emergency Preparedness Course (ASMEP) Registration Form (Please Print)

Rev 04-2017

COURSE DESCRIPTION:

This New York City Fire Department (FDNY) accredited course is required for existing Fire Safety Directors (FSD), Fire Safety and Emergency Action Plan (FS/EAP) Directors and new Fire & Life Safety (FLS) Directors. This course is also available to the public and may be of interest to building owners or others responsible for the safety of individuals within an occupied building. Ultimately, the FSD and FS/EAP Certificate of Fitness (COF) will be replaced by a single COF, the FLS Director (F-89), which will be used in both office buildings and hotels. To begin this transition, per RCNY 113, of the 2014 NYC Fire Code, the ASMEP training must be successfully completed by 9/4/17 or before the expiration of the current Certificate of Fitness (COF) for all existing FS/EAP, FSD and new FLS Director applicants. To transition from a current FS/EAP Director (F-59) COF

Successfully complete the ASMEP Course to receive the FLS Director (F-89 COF). Expiration date of original F-59 COF to carry over to new FLS Director COF (F-89 COF). To transition from a current FSD (F-25/F-58) COF Will be 2 phase process with the 1

st phase requiring the

successful completion of the ASMEP Course to receive the FSD with Active Shooter Prep (F-85) COF. Expiration date of original F-58 COF to carry over to new F-85 COF. Phase 2 will require the successful completion of the EAP Training course, FDNY CBT Exam and FDNY on-site exam to receive the F-89 COF. PLEASE NOTE: Candidates MUST provide a copy of their current Z-25/F-58 or F-59 COF and a valid mailing address at the time of training to receive the new COF. The FDNY will directly mail the new COF approximately 2-3 weeks after completing the ASMEP training. COURSE COMPLETION: Students are required to complete 100% of the course to be eligible to participate in the required graduation exam. Students must receive a minimum passing score of 70% on the 20-question multiple-choice exam to receive the course completion certificate and verification letter.

HOW TO REGISTER

ONLINE: Please visit www.tscta.com EMAIL: Send completed form to Info@tscta.com FAX: Send completed form to 718-389-6155

COURSE FEES are due in full in order to be eligible to receive course completion materials. Fees include cost of all training materials.

• Individual Course Fee: $100.00 per participant • For 10 or more attendees: $90.00 per participant

ACCEPTED FORMS OF PAYMENT:

Cash

Credit card (see form below)

Money order/certified check

Check (7 day hold for release of materials)

SELECT DISTRIBUTION OPTION

Release Materials to the student after class; OR

Mail materials to company address

REGISTRATION, CANCELLATION & ATTENDANCE POLICY

Seating will not be reserved without completed registration form and payment. After registration, confirmation will be provided by fax, email or printed copy. Registration forms sent in to office after 5 PM will be processed the following business day.

ATTENDANCE: TSCTA requires 100% attendance to satisfy course requirements. Students must arrive no later than 30 minutes after start of training to be admitted.

CANCELLATION or rescheduling requests will be accepted with no penalty at least 3 business days prior to training start date. Failure to provide adequate notice may result in forfeiture of deposit. Registrations made less than 3 days before event start date will not be eligible for a refund. No cash refunds will be issued. TSCTA reserves the right to reschedule or cancel any course date(s) for any reason, including insufficient enrollment. To view TSCTA’s registration, refund, classroom, privacy and non-discrimination policies, please visit www.tscta.com.

SECTION 1

CLASS DATE:

COF TYPE/#

SECTION 2

* Home address will be used by FDNY to mail updated COF*

NAME

ADDRESS APT #

CITY STATE ZIP

HOME # CELL#

DATE OF BIRTH

EMAIL

SECTION 3

COMPANY/SPONSOR NAME

COMPANY CONTACT

COMPANY ADDRESS

CITY STATE ZIP

EMAIL

WORK# FAX#

F-58 or F-59

Credit Card Authorization Form Phone: 718.389.2103 Fax: 718.389.6155 Email: info@tscta.com Website: www.tscta.com

I, ________________________________________ hereby authorize TSC Training Academy, LLC to charge the below credit card for the authorized amount. I have read and reviewed

TSCTA’s cancellation and refund policy and agree to the terms as written. I understand that failure to provide three (3) days advance notification of registration cancellation may result in forfei-

ture of payment (s). Further, no course completion material (s) will be released until ALL account balances have been paid in full.

Card No: _____________________________________________________________ Expiration Date: ___________ Verification Code: ________

Card member acknowledges receipt of goods and or services in the amount of the total shown hereon and agrees to perform the obligations set forth by the card member’s agreement with the issuer.

CREDIT CARD ON FILE

Card holder name CHECK THIS BOX TO AUTHORIZE TSCTA TO SAVE YOUR CREDIT

CARD INFO ON FILE FOR ALL FUTURE TRAINING BALANCES ON

YOUR ACCOUNT. A CREDIT CARD RECEIPT WILL BE EMAILED TO

YOU EACH TIME A CHARGE IS MADE.

Company Name (if applicable)

Street Address

RELEASE OF MATERIALS

Phone

Name of person preparing form (if different than card holder)

City State Zip

RELEASE COMPLETION MATERIALS DIRECTLY TO

STUDENTS AT THE END OF COURSE (IF AVAILABLE).

MAIL COMPLETION MATERIALS TO ADDRESS

BREAKDOWN OF CHARGES

Date of Training Course Name # of Students Fee Per Student Total

Total Amount to be charged

CREDIT CARD DETAILS

VISA MASTERCARD DISCOVER AMEX

Card Holder’s Signature: ______________________________________________ Date: _________________

NOTE: One form can be used for multiple registrations

7/14/17.SV