EMS Training Inc. - Registration Form

Course Application

First Name
Last Name
Street Address
City
State	Zip
Email Address
Telephone Number
Pager Number
	Course
Course Name
Location:
Starting Date:
	Current Certifications
	CPR for Healthcare Providers
	CPR Instructor
	First Responder
	First Responder Instructor
	Previous EMT
	Reason for Taking Course:

NOTE: The Office of Emergency Medical Services (OEMS) requires 100% attendance of all students and a passing grade of at least 70% in order to successfully complete the course and be eligible to take the state certifying EMT written and practical exam.