EMT / AEMT Identification and Certification Information

Certified Provider's Name as it Appears on EMT Card

EMT #

Current Certification Level of Care

- Select -AEMT - ParamedicAEMT - Critical Care TechnicianAEMTEmergency Medical TechnicianCertified First Responder

Course #

Current Certification Expiration Date

EMT Personal Phone Number

EMT Email Address

EMT Email Address

Email Confirmation

EMT Current Personal Mailing Address

Address

Address 2

City/Town

State/Province

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP/Postal Code

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