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B & H EMT - ORIGINAL COURSE REGISTRATION FORM
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EMT Original
Select which course you are registering for: *
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6/12 - 8/17 Mon./Wed. 9 am-5pm, EO 102
5/17 - 9/13 Mon./Wed. 6:15 pm-10:15 pm, EO 103
5/29 - 6/22 Mon/Tues/Wed/Thurs. 9AM- 5PM, EO 104
7/17 -8/17 Mon/Tue/Wed/Thur 9AM -5PM EO 107
7/18 -11/16 Tues /Thurs 6:15PM-10:15PM EO 106
Last Name
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First Name
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Address 1
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Type in your street address
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Apt. #
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City
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State
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Zip Code
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County
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i.e. Kings (Brooklyn)OUTS(out of state)
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Date of Birth
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Gender
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Male
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Last 4 Digits of your Social Security Number
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Phone Number
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Please place the best phone number we can reach you on.
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Email Address
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Please place the Email Address we can best contact you on.
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4-digit NYS Agency code
(if you are a member of a NYS EMS Agency)
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How did you hear about us?
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Referred by
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