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Get NJ EMS-80 2012-2024

New Jersey Department of Health Office of Emergency Medical Services OEMS EMT TRAINING FUND CERTIFICATE OF ELIGIBILITY FOR EMT EDUCATION Please type or print legibly. Name of Student EMS ID Number Name of Eligible Volunteer EMS Agency Student Address City County State Zip Course Sponsor Course Start Date Course Number Course Title The undersigned verifies that All of the information above is true and accurate. New Jersey Department of Health Office of Emergency Medical Services OEMS EMT TRAINING FUND CERTIFICATE OF ELIGIBILITY FOR EMT EDUCATION Please type or print legibly. Name of Student EMS ID Number Name of Eligible Volunteer EMS Agency Student Address City County State Zip Course Sponsor Course Start Date Course Number Course Title The undersigned verifies that All of the information above is true and accurate. The EMT candidate listed above meets the following criteria a* Possession of valid CPR course completion documentation to the level of professional rescuer by a vendor approved by OEMS* b. Is a member in good standing of the Eligible Volunteer EMS Agency listed above. c* Has NOT attempted more than one Initial EMT education program this calendar year. d. Has NOT used the EMTTF for initial EMT education more than twice since July 1 2012. Verified by Name of Principal Officer Print Title Contact/Telephone Number Email Address Signature of Principal Officer Date NOTICE It is a crime for any person to knowingly or willfully provide false information on this application or to make deliberately misleading statements regarding the eligibility of applicants. N*J*S*A. 2C 21-4 s. I understand there is a best practices guideline that the Department has published for student selection and our organization has considered the suggestions before issuing this Certificate of Eligibility. Name of Student EMS ID Number Name of Eligible Volunteer EMS Agency Student Address City County State Zip Course Sponsor Course Start Date Course Number Course Title The undersigned verifies that All of the information above is true and accurate. The EMT candidate listed above meets the following criteria a* Possession of valid CPR course completion documentation to the level of professional rescuer by a vendor approved by OEMS* b. The EMT candidate listed above meets the following criteria a* Possession of valid CPR course completion documentation to the level of professional rescuer by a vendor approved by OEMS* b. Is a member in good standing of the Eligible Volunteer EMS Agency listed above. c* Has NOT attempted more than one Initial EMT education program this calendar year. Is a member in good standing of the Eligible Volunteer EMS Agency listed above. c* Has NOT attempted more than one Initial EMT education program this calendar year. d. Has NOT used the EMTTF for initial EMT education more than twice since July 1 2012. Verified by Name of Principal Officer Print Title Contact/Telephone Number Email Address Signature of Principal Officer Date NOTICE It is a crime for any person to knowingly or willfully provide false information on this application or to make deliberately misleading statements regarding the eligibility of applicants. .

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