Military Extension | Survey Builder

Providers may be eligible for a military extension under the following circumstances:

They were on active military duty orders that do not include training,
Their certification must expire during the period that they are on active military service, or within six months of separation,
The request for an extension must be submitted after release from active service.

Contact information

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Birth date

EMT Number

Certification Level

Certification Expiration Date

Branch of Military

Discharge or Release

Please upload a photocopy of your military Certificate of Release or Discharge from Active Duty (DD-214)

Signature

Sign above

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