What is your skill level?

Paramedic Intermediate EMT-B Other

Will you have a valid CPR-Professional Level card on course start date?    Yes No

Will you have a valid ACLS card on course start date?                                Yes No

What is your EMS Certificate Number?      State of Issuance   Expiration Date 

Are you currently on Extension?            Yes No

Are you under investigation or have you received Administrative Action from the Ohio EMS Board?   No Yes

What is you mailing address?

Tell us how to get in touch with you:

Name
E-mail
Tel
FAX

I am making application for the following;

    Refresher Course  -  Fee $150
    ACLS Refresher    -  Fee $75
    PALS Refresher     -  Fee $75

Total Course Fee Due is $150 - Refresher ONLY $225 - Refresher plus ACLS OR PALS $300 - Refresher plus ACLS AND PALS

  Our Federal EIN number is 20-2138457.

How would you like to pay for this course?

    Pay By Check    Pay by Credit Card    Invoice Me    Invoice My Department

Contact Name: Department Name: Department Address:

 

Please contact me as soon as possible regarding this matter.