Full Legal Name*

Prefix First Last Suffix

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Phone*

Email*

Employer

Work Address

Street Address Address Line 2 City State ZIP Code

Work Phone

OK to contact me at work?

Yes
No

Other Phone

Education Level:*

High School Diploma
GED
Some College
College Degree

Current Certification:*

EMR
EMT
EMT-Intermediate
None

Course Requested:*

EMR
EMT
Advanced EMT
CE
Other

Electronic Applicant Signature*

Please type your name.

Information obtained from this form is authorized by state and federal laws prohibiting discrimination on the basis of race, sex, age, religion, national origin or handicap. *Note: Date of birth is requested to verify that the applicant will be 18 years of age at the time of NR/TDSHS registry (for EMS certification courses), in accordance with state law and NR/TDSHS Rules.

Non-Profit Air Ambulance

Academy Application

Guardian Plan

Events

Sky High Rollers CASINO Night

Flights of Angels Golf Tournament