Training Request Form
Jurisdiction/Agency/Department *
Your answer
Requester Name (Last, First, Middle Inital, suffix) *
Your answer
Email Address *
Your answer
Preferred Phone *
Your answer
Alternate Phone *
Your answer
Course Title and Provider (i.e. MEMA, TEEX, LSU, etc) *
Your answer
This training request fulfills the following need(s): Check all that apply *
Required
Course Date(s): First Choice *
Your answer
Course Date(s): Second Choice *
Your answer
Course Date(s): Third Choice
Your answer
Class Location (Enter location name, full address including room number if applicable) *
Your answer
Number of student seats available in the class *
Your answer
Minimum number of students required for the course to be conducted *
Your answer
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 MEMA Learning Management System (LMS) unless an alternate method is agreed upon by MEMA 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 *
Your answer
Submit
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