EMS-56, Application for Certification, EMT-Basic Instructor
New Jersey Department of Health
Office of Emergency Medical Services
P. O. Box 360
Trenton, NJ 08625-0360
APPLICATION FOR CErtificatION AS AN
EMERGENCY MEDICAL TECHNICIAN-BASIC INSTRUCTOR
|DEMOGRAPHICS |
|Name |Social Security Number |
| | |
| |Date of Birth |
| | |
|Mailing Address (Required for OEMS Use Only. Must be a physical address; no PO Box or Mail Stop numbers | |
|accepted.) | |
| | |
| | |
| | |
| | |
| |Home Telephone Number |
| | |
| | |
|City State Zip Code | |
| | |
| | |
| | |
| |Work Telephone Number |
| | |
| | |
| | |
|Public Address (Optional - the Department will provide this address for requests of government records.) | |
| | |
| | |
| |Cell Phone Number |
| | |
| | |
| | |
| | |
|City State Zip Code | |
| | |
| |Email Address |
| | |
| | |
| | |
| | |
| | |
|AFFILIATION |
|EMT Course Affiliation |
| |
|Course Coordinator |Coordinator Contact Number |
| | |
|Level of Certification |Certification Number |
| | |
|EXPERIENCE |
|Years Certified |Years EMS Experience |Total Teaching Time as Aide |Total Teaching Hours |
| | | | |
|EDUCATIONAL BACKGROUND |
|School |Dates |Graduated |Major |
|High School | | | |
| | | | |
|College | | | |
| | | | |
|Graduate | | | |
| | | | |
|Other | | | |
| | | | |
I verify that all of the above information and attached supporting documentation is correct and factual. I understand that any discrepancies may be cause for disqualification from the EMT Instructor candidate screening process.
|Signature |Date |
NOTE: Please include a copy of your resume, coordinator letter of recommendation, and two additional letters of recommendation with this application.
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