Appendix E Dec 2017

REQUEST FOR RECIPROCITY APPLICATION

Name Social Security #

Address Date of Birth

(Last Four Digits)

City State Zip

County Home Phone Alternate Phone

RECIPROCITY LEVEL REQUESTED

Firefighter I Driver/Operator - Pumper

Firefighter II Driver/Operator - Aerial

Fire Service Instructor I Driver/Operator - Mobile Water

Fire Service Instructor II Rescue Technician – Vehicle/Machinery

Fire Officer I Rescue Technician – Vehicle/Machinery I

Fire Officer II Rescue Technician – Vehicle/Machinery II

Airport Firefighter Rescue Technician – Rope

Fire Investigator Rescue Technician – Confined Space

Fire Inspector I Rescue Technician – Structural Collapse

HazMat Awareness Rescue Technician – Trench

HazMat Operations Rescue Technician – Surface Water

HazMat Technician Juvenile Firesetter Intervention Specialist I

HazMat Incident Commander Juvenile Firesetter Intervention Specialist II

Incident Safety Officer Industrial Fire Brigade - Incipient

Public Fire & Life Safety Educator I Industrial Fire Brigade - Advanced Exterior

Public Fire & Life Safety Educator II

NOTE: MUST BE A PENNSYLVANIA RESIDENT and PROOF OF CERTIFICATION MUST BE ATTACHED TO THIS APPLICATION

Effective January 1, 2010, applicants requesting reciprocity will be charged a fee of $15.00; PLUS $5.00 per level requested. Payment must be made in the form of a check or money order, payable to the

“Commonwealth of Pennsylvania”. Please refer to instruction sheet on the following page for additional information.

Mail application to: Pennsylvania State Fire Academy Attn: Certification Program-Reciprocity

1150 Riverside Drive Lewistown, PA 17044

Appendix E Dec 2017

REQUEST FOR RECIPROCITY APPLICATION INSTRUCTIONS 1. Complete application

2. Attached copies of Certification Certificates (IFSAC or Pro-Board). 3. Please make sure to enclose a check or money order with your application

(Payable to Commonwealth of PA)

Note:

• Certification Reciprocity will not be given for completion of training. We will only issue for National Certifications.

• We cannot issue reciprocity for a level that we are not accredited or before a date that we were

accredited. (See list below)

Table Revised Feb 2017

Level /NFPA Standard Pro-Board Accredited

IFSAC Accredited

Pro-Board

Date

Accredited

IFSAC

Date

Accredited

HazMat Awareness - 472 X X 2003 7/26/08

HazMat Operations - 472 X X 2003 7/26/08

HazMat Technician - 472 X X 2003 5/31/11

HazMat Incident Commander X X 10/21/14 9/20/14

Fire Fighter I - 1001 X X 1985 7/26/08

Fire Fighter II - 1001 X X 1985 7/26/08

Driver/Operator - Pumper - 1002 X X 2003 9/11/09

Driver/Operator - Aerial - 1002 X X 2008 9/11/09

Driver/Operator – Mobile Water Supply 1002 X X 2008 9/11/09

Airport Fire Fighter - 1003 X X 2003 9/11/09

Fire Officer I - 1021 X X 1996 7/26/08

Fire Officer II - 1021 X X 1996 7/26/08

Fire Investigator I - 1033 X X 1997 10/13/14

Fire Inspector I - 1031 X X 2009 11/10/09

Fire Service Instructor I - 1041 X X 1992 6/29/09

Fire Service Instructor II - 1041 X X 1994 6/29/09

Incident Safety Officer - X X 3/30/15 12/29/14

Pub. Fire & Life Safety Educator I - 1035 X X 2008 6/29/09

Pub. Fire & Life Safety Educator II - 1035 X X 1/19/17 7/31/16

Juvenile Firesetter Intervention Specialist I X X 2008 6/29/09

Juvenile Firesetter Intervention Specialist II X X 3/30/15 12/29/14

Confined Space Rescue Tech - 1006 X X 2005 ------------

Confined Space Rescue Tech Levels I/II X X 7/27/10 8/19/10

Rope Rescue Tech – 1006 X X 2003 -------------

Rope Rescue Tech Level I/II X X 7/27/10 5/31/11

Structural Collapse Rescue Tech – 1006 X X 2008 ------------

Structural Collapse Rescue Tech Level I/II X X 7/27/10 8/30/10

Surface Water Rescue Tech - 1006 X X 2008 Nov 2009

Surface Water Rescue Tech Level I/II X X 7/27/10 8/20/10

Trench Rescue Tech – 1006 X X 2004 -------------

Trench Rescue Tech Levels I/II X X 7/27/10 8/9/10

Vehicle & Machinery Rescue Tech – 1006 X X 2003 --------------

Vehicle & Machinery Rescue Tech Level I X X 7/27/10 5/31/11

Vehicle & Machinery Rescue Tech Level II X X 7/27/10 5/31/11

Incipient – Industrial Fire Brigade - 1081 X X 10/22/10 6/16/2011

Advanced Exterior – Industrial Fire Brigade -1081 X X 1/27/11 6/16/2011