Use this form to let DFA know if your municipality (or you as an individual) are  interested in scheduling training. Completing this form will assist DFA in coordinating training opportunities for municipal employees. Once we receive enough requests, we will contact you concerning the date of the training. Then fax it to John Kenney at (617) 626-1850 or mail it to him at the Department of Food & Agriculture, 251 Causeway Street, Suite 500, Boston, MA 02114.

Name __________________________________________

Title     __________________________________________

Municipality/Entity Name ____________________________

Business Address ________________________________

City   _______________________  MA     ZIP ___________

Phone _________________   FAX ___________________

Cell ___________________

Email __________________________________________

 

Catch Basins to be treated _________________________

Number of employees to attend training   ______________

Names

_________________________     _________________________

_________________________     __________________________

_________________________     __________________________

 

Fax to:   John Kenney   (617) 626-1850

Or Mail to:

John Kenney

Department of Food & Agriculture

251 Causeway Street, Suite 500

Boston, MA 02114