Course Application
  1. Name:(*)
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  2. Address:
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  3. Home Phone:
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  4. Cell Phone:
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  5. Email:(*)
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  6. Primary EMS Affiliation:
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  7. Secondary EMS Affiliation:
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  8. NYS EMT Number:
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  9. Exp. Date:
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  10. Copy of Cards:
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  11. CPR Card Expiration:
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  12. ACLS Card Expiration:
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  13. PALS Card Expiration:
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  14. ITLS Card Expiration:
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  15. Course for which Applying:
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  16. Course Date:(*)
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  17. Will you need a new textbook through the Training Center?:
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  18. Will you need a new workbook through the Training Center?:
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  19. In case of an emergency, who do we contact? (Name Address Phone):
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  20. Note Remarks or Special Accommodations needed:
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  21. (*)

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