Section 1565.EXHIBIT A Certified Prescribed Burn Manager Application

Directions: All applicants must complete PART A and attach the required documentation and submit any required fee to the Illinois Department of Natural Resources, Attention Prescribed Burn Manager Certification, One Natural Resources Way, Springfield IL, 62702-1271. Each applicant must complete either Part B, C or D and the documentation listed in that Part.

PART A:

SECTION A1: IDENTIFICATION*

Applicant Name:
Employer's Name (if applicable):
Applicant Address (Street Address, City, State, Zip Code):

Applicant Phone Number:
Applicant Date of Birth:

*Please provide a copy of your driver's license or other government issued identification card.

SECTION A2: CLASSROOM TRAINING**

Course Name:		Date:
Course Name:		Date:
Course Name:		Date:

**Attach copies of all listed course completion certificates. If additional space is needed to list courses, then attach a separate sheet listing course work.

SECTION A3: FEE

CHECK THIS BOX IF YOU ARE A STATE OF ILLINOIS EMPLOYEE AND EXEMPT FROM THE CERTIFICATION FEE: OTHERWISE, INCLUDE CHECK OR MONEY ORDER FOR $50 MADE PAYABLE TO THE ILLINOIS DEPARTMENT OF NATURAL RESOURCES.

SECTION A4: SIGNATURE

I certify that the information provided in this application is correct.

Applicant:

Date:

PART B:

SECTION B1: PRESCRIBED BURN PARTICIPATION

1)	Location:	Date:
2)	Location:	Date:
3)	Location:	Date:
4)	Location:	Date:
5)	Location:	Date:

SECTION B2: PRESCRIBED BURNS WHERE APPLICANT SERVED AS AN APPRENTICE PRESCRIBED BURN MANAGER*

I have reviewed Section A and B1 and accept the above named person as an Apprentice Prescribed Burn Manager.

Certified Prescribed Burn Manager:
		(Signature)		(Date)
Name:			Certificate Number:
	(Type or Print)

1)	Location:			Date:
Certified Prescribed Burn Manager Supervising the Apprentice Prescribed Burn Manager
Name:			Certificate Number:
		(Type or Print)

2)	Location:			Date:
Certified Prescribed Burn Manager Supervising the Apprentice Prescribed Burn Manager
Name:			Certificate Number:
		(Type or Print)

*Attach copies of relevant Prescribed Burning Plans, Prescribed Burn Reports and performance evaluations signed by a Certified Prescribed Burn Manager supervising the Apprentice Prescribed Burn Manager.

PART C:

PREVIOUS PRESCRIBED BURN MANAGEMENT EXPERIENCE: Complete and notarize this part ONLY if you are claiming exemption from the apprentice requirements due to previous experience as a prescribed burn manager. Part C cannot be completed after December 31, 2010.

Pursuant to 17 Ill. Adm. Code 1565.20(d), prior to July 1, 2009, I have participated in at least seven prescribed burns, including at least five at which I have served as the Certified Prescribed Burn Manager.

By:
	(Applicant's Signature)

STATE OF ILLINOIS
COUNTY OF

Signed and sworn (or affirmed) to before me this		day of
by
	(applicant's name)

(Signature of Notary Public)

(SEAL)

PART D:

Complete this part ONLY if you hold certification from another state that meets or exceeds the requirements of an Illinois Prescribed Burn Manager Certificate or hold a valid prescribed burn certification for a Prescribed Fire Boss under the NIIMS Wildfire Qualification System and you are claiming you qualify for an Illinois Certificate pursuant to 17 Ill. Adm. Code 1565.20(e) or (f).

Check the following box or boxes that apply:

I hold a valid Prescribed Burn Manager Certificate or its equivalent from 15724_________ (list state) and have attached to this application a copy of that certificate and a copy of my application used to obtain the certificate, or an official document from that state listing the general qualifications for certification.

I hold certification as a Prescribed Fire Burn Boss Type 1 (RXB1) or Type 2 (RXB2) through the NIIMS Wildfire Qualification System and have attached a copy of that certification to this application.

I certify that the above information is correct.

Applicant's Signature:

Date: