nfa.qwake.tech
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https://nfa.qwake.tech/
Submission: On July 04 via api from US — Scanned from CH
Submission: On July 04 via api from US — Scanned from CH
Form analysis 1 forms found in the DOM
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<div class="hs-richtext hs-main-font-element">
<h3>Section 1: Applicant Information</h3>
</div>
</div>
<div class="hs_email hs-email hs-fieldtype-text field hs-form-field"><label id="label-email-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your Email"
for="email-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Email</span><span class="hs-form-required">*</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="email-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="email" required="" placeholder="" type="email" class="hs-input" inputmode="email" autocomplete="email" value=""></div>
</div>
<div class="hs_firstname hs-firstname hs-fieldtype-text field hs-form-field"><label id="label-firstname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your First name"
for="firstname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>First name</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="firstname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="firstname" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="given-name" value=""></div>
</div>
<div class="hs_lastname hs-lastname hs-fieldtype-text field hs-form-field"><label id="label-lastname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your Last name"
for="lastname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Last name</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="lastname-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="lastname" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="family-name" value=""></div>
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<div class="hs_current_role hs-current_role hs-fieldtype-select field hs-form-field"><label id="label-current_role-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your Department Job Title"
for="current_role-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Department Job Title</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><select id="current_role-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="hs-input is-placeholder" name="current_role">
<option disabled="" value="">Please Select</option>
<option value="Asst. Fire Chief">Asst. Fire Chief</option>
<option value="Lt">Lt</option>
<option value="Commissioner">Commissioner</option>
<option value="Lieutenant">Lieutenant</option>
<option value="Dept Fire Chief">Dept Fire Chief </option>
<option value="Dept Captain">Dept Captain</option>
<option value="Engineer">Engineer</option>
<option value="Firefighter">Firefighter</option>
<option value="Safety Officer">Safety Officer</option>
<option value="Firefithter">Firefithter</option>
<option value="Volunteer">Volunteer</option>
<option value="Assistant Chief of Operations">Assistant Chief of Operations</option>
<option value="Division Chief">Division Chief</option>
<option value="FF/PM">FF/PM</option>
<option value="FFPM">FFPM</option>
<option value="Fire marshal">Fire marshal</option>
<option value="Group Commander">Group Commander</option>
<option value="Company Lieutenant">Company Lieutenant</option>
<option value="Assistant Fire Chief">Assistant Fire Chief</option>
<option value="Deputy Fire Chief">Deputy Fire Chief</option>
<option value="Director">Director</option>
<option value="Assistant Chief">Assistant Chief</option>
<option value="Capt">Capt</option>
<option value="Battalion CHief">Battalion CHief</option>
<option value="Title">Title</option>
<option value="Chief Instructor">Chief Instructor</option>
<option value="Training Captain">Training Captain</option>
<option value="Sales of equipment">Sales of equipment</option>
<option value="lut.">lut.</option>
<option value="Iron Firefighter">Iron Firefighter</option>
<option value="VP">VP</option>
<option value="Driver Operator">Driver Operator</option>
<option value="FF">FF</option>
<option value="Fire Inspector/EMT">Fire Inspector/EMT</option>
<option value="Quartermaster">Quartermaster</option>
<option value="Firefighter paramedic">Firefighter paramedic</option>
<option value="VH">VH</option>
<option value="Deputy Chief">Deputy Chief</option>
<option value="Lead">Lead</option>
<option value="Fire marshall">Fire marshall</option>
<option value="Shift commander">Shift commander</option>
<option value="Sr. Instructor">Sr. Instructor</option>
<option value="sgto">sgto</option>
<option value="Lt.">Lt.</option>
<option value="Senior Instructor">Senior Instructor</option>
<option value="Training Officer">Training Officer</option>
<option value="Division Chief/Training">Division Chief/Training</option>
<option value="Fire fighter">Fire fighter</option>
<option value="Assistant chief Operations">Assistant chief Operations</option>
<option value="Driver Engineer">Driver Engineer</option>
</select></div>
</div>
<div class="hs_0-2/name hs-0-2/name hs-fieldtype-text field hs-form-field"><label id="label-0-2/name-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your Fire Department Name"
for="0-2/name-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Fire Department Name</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/name-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/name" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
</div>
<div class="hs-dependent-field">
<div class="hs_0-2/department_governance hs-0-2/department_governance hs-fieldtype-select field hs-form-field"><label id="label-0-2/department_governance-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class=""
placeholder="Enter your What type of department governance applies?" for="0-2/department_governance-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>What type of department governance applies?</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><select id="0-2/department_governance-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="hs-input is-placeholder" name="0-2/department_governance">
<option disabled="" value="">Please Select</option>
<option value="Fire District">Fire District</option>
<option value="City Department">City Department</option>
<option value="Other (please specify)">Other (please specify)</option>
</select></div>
</div>
</div>
<div>
<div class="hs-richtext hs-main-font-element">
<p style="font-size: 18px;">Please fill in the HQ Address</p>
</div>
</div>
<div class="hs_0-2/address hs-0-2/address hs-fieldtype-text field hs-form-field"><label id="label-0-2/address-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your HQ Street"
for="0-2/address-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>HQ Street</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/address-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/address" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="address-line1" value=""></div>
</div>
<div class="hs_0-2/city hs-0-2/city hs-fieldtype-text field hs-form-field"><label id="label-0-2/city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your HQ City"
for="0-2/city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>HQ City</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/city" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="address-level2" value=""></div>
</div>
<div class="hs_0-2/state hs-0-2/state hs-fieldtype-text field hs-form-field"><label id="label-0-2/state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your HQ State/Region"
for="0-2/state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>HQ State/Region</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/state" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="address-level1" value=""></div>
</div>
<div class="hs_0-2/zip hs-0-2/zip hs-fieldtype-text field hs-form-field"><label id="label-0-2/zip-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="" placeholder="Enter your HW Postal code"
for="0-2/zip-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>HW Postal code</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/zip-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/zip" placeholder="" type="text" class="hs-input" inputmode="text" autocomplete="postal-code" value=""></div>
</div>
<div>
<div class="hs-richtext hs-main-font-element">
<p style="font-size: 18px;">Please fill in the Training Facility Address</p>
</div>
</div>
<div class="hs_0-2/training_facility_address__street hs-0-2/training_facility_address__street hs-fieldtype-text field hs-form-field"><label id="label-0-2/training_facility_address__street-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class=""
placeholder="Enter your Training Facility Address: Street" for="0-2/training_facility_address__street-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Training Facility Address: Street</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/training_facility_address__street-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/training_facility_address__street" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
</div>
<div class="hs_0-2/training_facility_address__city hs-0-2/training_facility_address__city hs-fieldtype-text field hs-form-field"><label id="label-0-2/training_facility_address__city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class=""
placeholder="Enter your Training Facility Address: City" for="0-2/training_facility_address__city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Training Facility Address: City</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/training_facility_address__city-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/training_facility_address__city" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
</div>
<div class="hs_0-2/training_facility_address__zip_code hs-0-2/training_facility_address__zip_code hs-fieldtype-text field hs-form-field"><label id="label-0-2/training_facility_address__zip_code-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class=""
placeholder="Enter your Training Facility Address: Zip Code" for="0-2/training_facility_address__zip_code-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Training Facility Address: Zip Code</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><input id="0-2/training_facility_address__zip_code-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" name="0-2/training_facility_address__zip_code" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
</div>
<div class="hs_0-2/training_facility_address__state hs-0-2/training_facility_address__state hs-fieldtype-select field hs-form-field"><label id="label-0-2/training_facility_address__state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class=""
placeholder="Enter your Training Facility Address: State" for="0-2/training_facility_address__state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237"><span>Training Facility Address: State</span></label>
<legend class="hs-field-desc" style="display: none;"></legend>
<div class="input"><select id="0-2/training_facility_address__state-efb87d5d-2183-4e4f-a59c-106f2f750512_6237" class="hs-input is-placeholder" name="0-2/training_facility_address__state">
<option disabled="" value="">Please Select</option>
<option value=""></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
</select></div>
</div>
<div class="hs_submit hs-submit">
<div class="hs-field-desc" style="display: none;"></div>
<div class="actions"><input type="submit" class="hs-button primary large" value="Next Section (2 of 4) >>"></div>
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</form>Text Content
Skip to content Open main navigation Close main navigation DHS NATIONAL FIELD ASSESSMENT FIRE DEPARTMENT PARTICIPANT APPLICATION Application Form for Fire Department Participation in the National Field Assessment (NFA) Thank you for your interest in participating in the National Field Assessment (NFA) for Qwake Technologies' C-THRU platform. This is a unique opportunity to be among the first to experience and provide feedback on a groundbreaking technology solution designed to enhance firefighter safety and efficiency. Selected departments will receive C-THRU wearable navigation equipment and helmets, along with an Assessment plan and anonymized feedback forms. All data collected will be used strictly for the assessment and optimization of this exciting new technology. No personally identifiable information will be shared or published. Applications are due by July 31, 2024. Application will be accepted after this date, but selection will be done on a rolling basis, so candidate departments are encouraged to submit applications as soon as possible - the earlier you submit, the better your chances. Your application will be complete once you submit all four sections. After each section, please hit the 'Next Step' button to go to the next section. SECTION 1: APPLICANT INFORMATION Email* First name Last name Department Job Title Please SelectAsst. Fire ChiefLtCommissionerLieutenantDept Fire Chief Dept CaptainEngineerFirefighterSafety OfficerFirefithterVolunteerAssistant Chief of OperationsDivision ChiefFF/PMFFPMFire marshalGroup CommanderCompany LieutenantAssistant Fire ChiefDeputy Fire ChiefDirectorAssistant ChiefCaptBattalion CHiefTitleChief InstructorTraining CaptainSales of equipmentlut.Iron FirefighterVPDriver OperatorFFFire Inspector/EMTQuartermasterFirefighter paramedicVHDeputy ChiefLeadFire marshallShift commanderSr. InstructorsgtoLt.Senior InstructorTraining OfficerDivision Chief/TrainingFire fighterAssistant chief OperationsDriver Engineer Fire Department Name What type of department governance applies? Please SelectFire DistrictCity DepartmentOther (please specify) Please fill in the HQ Address HQ Street HQ City HQ State/Region HW Postal code Please fill in the Training Facility Address Training Facility Address: Street Training Facility Address: City Training Facility Address: Zip Code Training Facility Address: State Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming © 2024 QWAKE TECHNOLOGIES® INC, SAN FRANCISCO, CALIFORNIA, ALL RIGHTS RESERVED. Copyright © 2024, Qwake Technologies