NERRTC

Enhanced Incident Management / Unified Command Application

* Denotes required fields
Personal Information
Prefix
* First Name
Middle Initial
* Last Name
Preferred Name
* Date of Birth MM/DD/YYYY
M/F*
Contact Information
* Work Address 1
Address 2
* City
* State
* Zipcode
*Work Phone
- -
* Home Address 1
Address 2
* City
* State
* Zipcode
*Cell Phone
- -
Fax
- -
* Email
* Verify Email
Job Description
* Job Title
* Agency
* Discipline
* Level of Govt
Supervisor Point of Contact
In case we are unable to reach you with questions regarding your training application, please indicate your Supervisor Point of Contact within your organization that we may contact.
* First Name
* Last Name
* Job Title
* Work Phone
- -
* Email
* Verify Email

Personal Information Agreement

I authorize the release of my personal information by the Texas Engineering Extension Service (TEEX) for the purpose of verifying my attendance at the TEEX Enhanced Incident Management/Unified Command course and coordinating travel arrangements for such course.  TEEX offers to facilitate arrangements with third-party suppliers that sell travel-related services (i.e., air and ground transportation, hotel accommodations, meals, tours, cruises, etc.) solely as a convenience to its customers.  Therefore, TEEX shall not be responsible for any breach of contract of any intentional or careless actions or omissions on part of such suppliers, which result in any loss, damage, delay, or injury to you or your travel companions or group members.