Southwestern Illinois EMS System
The following information is required to enroll you as an individual provider in our new certification management tool.
Email address *
First Name *
Your answer
Last Name *
Your answer
Illinois License Number *
Your answer
Primary License Level *
Secondary License Level
Primary Email *
Your answer
Personal Email
Your answer
Address 1 *
Your answer
Address 2
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Cell Phone Number *
Please enter you phone number in this format xxxxxxxxxx
Your answer
Cell Phone Provider *
Your answer
Primary Agency *
Secondary Agency
Tertiary Agency
Quaternary Agency
List all other agencies here
Your answer
A copy of your responses will be emailed to the address you provided.
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