Emergency Medical Responder (EMR) Training Program Provider Application

Name *

First

Last

Phone *

Email *

Training Program/Individual Name *

Training Program Address *

Address Line 1

Address Line 2

City

State

Zip Code

Required Course Information

Principal Instructor(s) *

Teaching Assistant(s)

Course Dates *

Course Location(s): *

Principal Instructor *

Required Documents

Documents Skills Name

Resumes For Each Principal Instructor & Teaching Assistant *

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Periodic Written & Skills Examination Documents *

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Final Written & Skills Examination Documentation *

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Sample Course Completion Certificate *

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Description of Program Facilities, Equipment, Examination Security & Student Record Keeping *

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Attestation

Date *

Electronic Signature *

First

Last

I attest that I have reviewed the S-SV EMS Agency EMR Training Program Approval/Requirements Policy (1004) and will comply with all requirements described therein. I further attest that the program meets or exceeds the NHTSA Educational Standards and Instructional Guidelines. I further attest that all information contained in this application and supporting documents is true and correct to the best of my knowledge.