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Date of Birth*

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Work Address

Street Address Address Line 2 City State ZIP Code

Work Phone

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Other Phone

Education Level:*

High School Diploma
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Current Certification:*

EMR
EMT
EMT-Intermediate
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Course Requested:*

EMR
EMT
Advanced EMT
CE
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Electronic Applicant Signature*

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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.

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