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Plicant Information I am applying for: Certified Lab Instructor Certified Instructor Coordinator EMT / AEMT Number Last Name First Name, middle initial Address City County State Zip Code Social Security Number Home Phone Date of Birth Work Phone Cell Phone E-Mail Address Section B. The above named EMT/AEMT has actively provided on-going, direct, hands-on, pre-hospital patient care with From Name of EMS Agency To Date Date Agency Code Signature of Chief Operations Officer or.

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