Emergency Medical Services
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1ANCILLARY COURSE
EMERGENCY MEDICAL SERVICES
CORE CME CREDIT
SUFFOLK COUNTY-NEW YORK
NON CORE CME CREDIT
TODAY’S DATE
-
-
PRINT ALL REQUIRED
INFORMATION
LAST NAME
FIRST NAME
M.
I
.
ADDRESS
TOWN
PHONE
-
-
EMT #
EXPIRATION DATE
CORP
OR
DEPARTMENT
EMS
EMT-B
EMT-CC
EMT-P
OTHER
LEVEL
OFFICIAL USE
ONLY
SUBJECT/TOPIC
CORE CREDIT
.
COUNTY #
NON CORE CREDIT
.
CLASS LOCATION
INSTRUCTOR
#
NAME & SIGNATURE
INST. I/C #
THIS BLANK FORM MAY BE PHOTOCOPIED AS REQUIRED
SUFFREG7a rev. 08/18/06
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