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.

EMS-56

JUL 12

EMS-56, Application for Certification, EMT-Basic Instructor

EMS-56, EMT-Basic, instructor, application for certification as EMT-Basic Instructor, emergency medical services, EMS

EWhite

2012-05-21

NJDOH