Applicant Information
Department / Organization
Fire Chief (Name):
Chief Fire Prevention Officer:
Mailing Address:
Title:	Email:
Phone:	Fax:
For Office Use Only
New Member: ☐	Renewal: ☐
Valid for Year of: Click here to select year	Payment Received: ☐	Click here to enter a date.
Please complete the top portion of this for. Return this form enclosing a cheque in the amount of $150 payable to:
OMFPOA c/o Gwen Lewis CFEI Assistant Division Chief Ottawa Fire Services 101 Centrepointe Drive, 3rd Floor Ottawa, ON K2G 5K7

Please assist us in creating a Provincial directory of persons assigned with fire prevention / education duties. Cell Phone is optional for those who would like to receive tweets or alerts. Cell phone numbers will not be posted on the website.	Pub-Ed	Inspection / Enforcement	Investigations	Plan Examiner (BCIN Req.)
Name (First and Last Only)	Title	Department	Email	Cell Phone (for those who would like to receive tweets or alerts)	Regular Duties (select all that apply
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Pub-Ed	Inspection / Enforcement	Investigations	Plan Examiner (BCIN Req.)
Name (First and Last Only)	Title	Department	Email	Cell Phone (for those who would like to receive tweets or alerts)	Regular Duties (select all that apply
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Pub-Ed	Inspection / Enforcement	Investigations	Plan Examiner (BCIN Req.)
Name (First and Last Only)	Title	Department	Email	Cell Phone (for those who would like to receive tweets or alerts)	Regular Duties (select all that apply
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