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Registration Form Emergency Services Training, LLC

110 Spruce Trail Woolwich, NJ 08085-4000 609-744-8537

Full Name: ______________________________________________________________________________________________ Organization Name/Sponsor (if any): _________________________________________________________________________ Preferred Mailing Address:__________________________________________________________________________________ City: ________________________________ State/Province: ______________________ Zip/Postal Code: _________________ County: _____________________________ Telephone: (______)__________________ Fax: (______)____________________ Email: __________________________________________________________________ NJ State EMT ID Number (if applicable): _______________________________________

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Registration PLEASE CHECK APPROPRIATE PAYMENT TYPE:

Training Fund Check PO Voucher

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Name of Class:______________________________________________________________________________________ Date of Class:_____________________________________________ Total Payment: $____________ Please list any ADA Special Needs: ____________________________________________________________________________________________ *if getting CEUs for NJEMT you will need to provide written documentation from a doctor Cancellations/Changes and Refunds: Fees will be refunded, less a $20.00 processing fee, if cancellation or change resulting in a refund is received in writing no later than 10 day prior to first day of class. After that date, fees are non-refundable. All refunds will be processed after the class. Substitutions are allowed at no charge but with notice.

PAYMENT METHOD: Check or Money Order must be in U.S. funds payable to: Emergency Services Training, LLC. There will be a $25.00 fee charged on checks returned by the bank due to insufficient funds. Registration confirmation/receipt and further information will be mailed or emailed. Please mail completed registration form with payment to: Emergency Services Training, LLC 110 Spruce Trail Woolwich, NJ 08085-4000


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