MDEM Training Request Form
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Email *
Requester Jurisdiction/Agency/Department *
Requester Name (Last, First, Middle Inital, suffix) *
Email Address *
Preferred Phone *
Alternate Phone *
Course Title and Provider (i.e. G-Course, NDPC, TEEX, LSU, etc) *
This training request fulfills the following need(s): Check all that apply *
Course Date(s): First Choice *
Course Date(s): Second Choice *
Course Date(s): Third Choice
Host Venue Address (Enter location name, full address including room number if applicable) *
Venue Point of Contact (Name, Email, Phone Number) *
Number of student seats available at host venue *
Minimum number of students required for the course to be conducted *
By requesting this course, I agree to the following:
All state sponsored training courses are delivered at no charge to the jurisdiction and/or participants.  This does not include costs incurred for travel, lodging and meals.  Course registration will be conducted through the MDEM Learning Management System (LMS) unless an alternate method is agreed upon by MDEM and the requester.  Person requesting the course must have the authority of their agency/department/jurisdiction prior to submitting the request.
Requester Signature and Date
(Your name below constitutes signature of this form)
Digital Signature *
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