School of Extended & Lifelong Learning
Nomination Form
Course Name (IQCS#): / For Unit Training Representative use:
S-270/271 Air Ops/HECM (712/747) / Priority of
Course Dates:
April 21-25, 2014 / Course Location:
NRTC- Bob Marshall Room / Course Tuition: $250
Nominations Due by: March 24, 2014
Course Coordinator:
Chris Johnson / Coordinator Phone:(Voice/Fax)
(406) 243-4638 / 243-2047 / Coordinator E-Mail:
Nominee's Name: / IQCS Number (if applicable) This may be found on your Red Card / Date Submitted:
Working Job Title:
/ Nominee’s Winter/Spring Email Address:
Billing/Sponsoring Agency(Name, Address): / Nominee's Winter/Spring Mailing Address
Telephone: / Nominee’s Phone Number:
List training completed and dates pertinent to this course:
Course: Date
List your current qualifications pertinent to this course:
Nominee's Signature:
I will notify my Unit Training Officer or the Course Coordinator if I am unable to attend so someone else can take my place.
Supervisor's Signature:
I certify the nominee meets the prerequisites, or if not met, I will put the reasons for attending the course in Remarks below.
Remarks:
Who should The University of Montana contact for tuition payment?
(This part must be completed in order to be considered for the course.)
Name Phone # email:
Method of Payment is: Check (Checks should be written to the University of Montana.)
Credit Card: Visa MasterCard (The card # may be called in later.)
Card #:______Expiration Date:__/___ Signature:______
Authorizing Signature that student meets prerequisites and payment will be made:
Name (Agency Training Representative, if applicable) Date
Send this completed nomination form through your training representative to:
Chris “CJ” Johnson, School of Extended & Lifelong Learning-UM, 32 Campus Dr #1728, Missoula, MT 59812-1728.
For questions regarding the registration process or course information contact Chris “CJ” Johnson, (see above).
For questions about billing, contact Amy Saltzman @ (406) 243-4623 or