Corporate Partnership Details

Incident Command Training Application

Name of Host Institution:

Name of Chief/Director:

Address1

Address2

Address3

Telephone

Fax:

Email:

Point of Contact First Name:

Point of Contact Last Name:

Point of Contact Title

Point of Contact Phone

Point of Contact Fax

Point of Contact Email:

Name of Training Facility to be designated for ICS Classes:

Room Name/number:

Facility Address

Facility City

Facility State

facility Zip

Shipping Information (We can not ship to a PO Box)

Building Name:

Room name/number:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Does Facility contain two classrooms, each with adequate space for up to 35 students and instructors? yes No

The Maximum count for the class is - please change if less than 35

Are these classrooms available for a period of two to four consecutive weeks for direct deliveries of IACLEA’s three-day ICS class? yes No

Do you have an IACLEA ICS instructor on your staff? yes No

Name the IACLEA ICS instructor on your staff who will teach this course:

Identify nearest major airport:

Indicate number of miles from airport to training site

Directions: Example

Identify the nearest available parking for 35 students and instructors.

Is the parking adjacent to the training site? Yes No

Is there a fee for parking? Yes No

Where is the nearest food service in relation to the training site?

Identify three hotels close to the training site that offer lodging within the federal government per diem rate
For the federal per diem rate, please go to this web site , click on the Per diem Rate link, and click on the state where your institution is located. A chart will appear listing per diem rates for lodging in various regions within your state.

Indicate your preferred course date you would like to offer the class

When Year:
Beginning month and day- Course Month (ie Nov 30 - Dec 1, would be 12)
Month:    Day:
Ending month and day
   final day of course:

Hour:

Identify two sets of alternate dates during a four week period when you would like to offer ICS classes

Identify campus public safety departments within driving distance (two hours or less) of your institution that would attend IACLEA’s three-day ICS class (you must list at least three campus public safety departments):

Identify non-campus law enforcement or emergency response agencies within driving distance (two hours or less) of your institution that would attend IACLEA’s three-day ICS class (you must list at least two non-campus agencies):

Date: 07/20/2008