Always Review for Accuracy:

Personal Profile

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First Name:


Last Name:


License Type:


CE Type (EMR and EMT = Basic, AEMT and Paramedic = Advanced):


Provide Your State License and/or NREMT Information:
License State:


License Number:


License Expiration Date:


NREMT Number:


NREMT Reregistration Date:


Your Address:
Address:


City:


State:


Zip:


Phone:




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