2013 K9 Registration Form - Missouri Division of Fire Safety

2013 MISSOURIDIVISION OF FIRE SAFETYK9 TEAMMUTUAL AID REGISTRATIONPLEASE TYPE OR PRINTMail, Fax or Email completed form to:MISSOURI DEPARTMENT OFPUBLIC SAFETYDIVISION OF FIRE SAFETYP.O. BOX 844JEFFERSON CITY, MO 65102FAX: 573-751-5710Email: mutualaid@dfs.dps.mo.govHANDLER NAME: 24 HR CONTACT #: ALT PHONE #:HANDLER ADDRESS (INCLUDING COUNTY):HANDLER EMAIL ADDRESS:6) DEPARTMENTAL AFFILIATION: 7) CHIEF/SUPERVISOR NAME AND CONTACT #:DEPARTMENT ADDRESS: CHIEF/SUPV. E-MAIL ADDRESS: DEPT. PHONE:DEPARTMENT TYPE:SEARCH & RESCUE TEAMFIRE DEPARTMENTLAW ENFORCEMENT AGENCYOTHER ______________________NO AFFILIATIONARE YOU AVAILABLE TO RESPOND:HANDLER QUALIFICATIONS/TRAINING [CHECK ALL THAT APPLY]:ICS 700 ICS 800ICS 100 ICS 200HAZMAT AWARENESSHAZMAT OPERATIONSCOLLAPSED STRUCTURE RESCUE CONFINED SPACE RESCUEROPE RESCUESWIFTWATER RESCUECRIME SCENE PRESERVATION BLOOD BORNE PATHOGENSK9 FIRST AIDFIRST AID/CPROTHER APPLICABLE HANDLER TRAINING:WITHIN REGION?STATEWIDE?OUT OF STATE?(CHECK ALL THAT APPLY)In order to be utilized as a K9 asset through the Statewide Mutual Aid System, the handler/K9 teammust have a current year K9 Mutual Aid registration filed with the Division of Fire Safety; Includecopies of applicable certifications with the form. This registration process does not guaranteedeployment nor imply financial reimbursement will be available to the deploying asset. Alldeploying assets retain personal or departmental responsibility for liability and workman’scompensation benefits.I certify that to my knowledge, the information contained in this document and any attachedsupporting documentation is true and accurate._________________________Handler name_________________________Handler signature___________DateFOR OFFICEUSE ONLYMutual Aid Region:Date received:

Please report all K9 resources that may be utilized for mutual aid responses. For K9/handler teamswho possess certifications in more than one discipline or from multiple agencies, provide detailsunder “ADDITIONAL CERTIFICATION INFORMATION.”K9 NAME: BREED/COLOR: DATE OF BIRTH: SEX:INTACT MALEINTACT FEMALENEUTERED MALESPAYED FEMALECERTIFYING AGENCY:FEMASUSARNORTH AMERICAN POLICE WORK DOG ASSOCIATIONNATIONAL ASSOCIATION OF SEARCH AND RESCUEINTERNATIONAL POLICE WORK DOG ASSOCIATIONAMERICAN RESCUE DOG ASSOCIATIONSEARCH AND RESCUE DOGS OF THE U.S.NATIONAL NARCOTICS DETECTOR DOG ASSOC.MAINE STATE POLICECANINE ACCELERANT DETECTION ASSOCIATIONAMERICAN WORKING DOG ASSOCIATIONOTHER_______________________________CERTIFICATION TYPE:AIR SCENT LIVEAIR SCENT HUMAN REMAINSDISASTER LIVEDISASTER HUMAN REMAINSWATER HUMAN REMAINSTRACKING/TRAILINGACCELERANTEXPLOSIVESAPPREHENSIONPROTECTIONNARCOTICSOTHER _______________________CERTIFICATION # DATE OF CERTIFICATION: CERTIFICATION EXPIRATION DATE:ADDITIONAL CERTIFICATION INFORMATION:K9 NAME: BREED/COLOR: DATE OF BIRTH: SEX:INTACT MALEINTACT FEMALENEUTERED MALESPAYED FEMALECERTIFYING AGENCY:FEMASUSARNORTH AMERICAN POLICE WORK DOG ASSOCIATIONNATIONAL ASSOCIATION OF SEARCH AND RESCUEINTERNATIONAL POLICE WORK DOG ASSOCIATIONAMERICAN RESCUE DOG ASSOCIATIONSEARCH AND RESCUE DOGS OF THE U.S.NATIONAL NARCOTICS DETECTOR DOG ASSOC.MAINE STATE POLICECANINE ACCELERANT DETECTION ASSOCIATIONAMERICAN WORKING DOG ASSOCIATION OTHER_______________________________CERTIFICATION TYPE/CAPABILITY:AIR SCENT LIVEAIR SCENT HUMAN REMAINSDISASTER LIVEDISASTER HUMAN REMAINSWATER HUMAN REMAINSTRACKING/TRAILINGACCELERANTEXPLOSIVESAPPREHENSIONPROTECTIONNARCOTICSOTHER _______________________CERTIFICATION # DATE OF CERTIFICATION: CERTIFICATION EXPIRATION DATE:ADDITIONAL CERTIFICATION INFORMATION: