!TEST NEW EVAL - CAPCE
How would you like your name to appear on your certificate?
Profession
Select Your Profession
EMS
EMT
Medic
Other
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What activities did you attend at the event?
Monday, May 6, 2019 – 8:00AM – 5:00PM
-- Select an Activity --
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Agreement
By completing this form, you attest that you have participated in all selected activities in thier entirety.
I agree
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Participant information (MUST PROVIDE TO RECEIVE CAPCE CREDITS):
State of licensure
State license number
Type/level of license, if applicable. Select one.
ACP - Advanced Care Paramedic
AEMT - Advanced Emergency Medical Technician
CFR - First Responder (all levels)
EMR - Emergency Medical Responder
EMT - Emergency Medical Technician
EMT-1
EMT-B
EMT-D
EMT-Int - Intermediate (all levels)
EMT-2
EMT-CC
EMT-P - Paramedic (all levels)
Paramedic
PCP - Primary Care Paramedic
Other
License expiration date (MM/YYYY)
NREMT registration number, if applicable
Next NREMT re-registration date, if applicable
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