Morris Sample 2 | Penn Tactical

MORRIS COUNTY

OFFICE OF EMERGENCY MANAGEMENT

CLASS REGISTRATION REQUEST FORM

1ST CHOICE DATE/TIME

2ND CHOICE DATE/TIME

SECTION I.

(FOR EMT/MICP ONLY)

IF YOU CURRENTLY POSSESS A NEW JERSEY EMT/PARAMEDIC CERTIFICATION, PLEASE COMPLETE THIS SECTION. IF YOU ARE NOT AN EMT/PARAMEDIC, PLEASE SKIP THIS SECTION AND MOVE TO SECTION II.

EMS ID NUMBER

DATE OF BIRTH

SECTION II.

(REQUIRED)

ALL OF THE FIELDS IN SECTION II – IV ARE REQUIRED FOR ALL STUDENTS.

IF YOU ARE AN NJ EMT/PARAMEDIC, PLEASE MAKE SURE THE INFORMATION YOU ENTER IN THIS SECTION MATCHES THE INFORMATION ON FILE WITH THE NJ DOH OEMS.

LAST NAME

FIRST NAME

PHONE

MAILING ADDRESS *

SECTION III.

(REQUIRED)

DEPARTMENT / AGENCY INFORMATION

PRIMARY AGENCY

SECONDARY AGENCY (If Applicable)

SECTION III.

(REQUIRED)

SIGN-UP QUESTIONNAIRE

HAVE YOU PREVIOUSLY COMPLETED THE MORRIS COUNTY BLEEDING CONTROL (B-CON) PROGRAM?

YES

IF YES, PLEASE PROVIDE THE DATE COMPLETED:

IMPORTANT INFORMATION REGARDING YOUR REQUEST

YOU WILL RECEIVE A CONFIRMATION EMAIL ONCE YOUR REGISTRATION INFORMATION HAS BEEN ENTERED INTO OUR TRAINING PORTAL. SEATS WILL BE FILLED ON FIRST COME FIRST SERVE BASIS. YOU ARE NOT REGISTERED FOR A CLASS UNTIL YOU RECEIVE AN EMAIL CONFIRMING YOUR SEAT.

PLEASE DIRECT ANY QUESTIONS REGARDING REGISTRATION REQUESTS TO MORRIS COUNTY OEM AT (973) 829-8600.

THANK YOU FOR YOUR INTEREST IN OUR TRAINING PROGRAMS

Penn Tactical

Solutions

DUNS: 117424078

CAGE Code: 8HQF1