Do Not Use - NEMTAC® Course Request Form

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Requ

Email *

Contact Name (First & Last):
*

Company Name:

Location (City & State):

Phone Number:
*

Course Desired *

Advanced Mobility Device Securement (AMDS)

Advanced Mobility Device Securement - Instructor (AMDS-I)

Certified Stretcher Operator (CSO)

Certified Stretcher Operator - Instructor (CSO-I)

Required

Number of Students:
*

Desired Course Date (1st Choice): *

YYYY

Desired Course Date (2nd Choice):

YYYY

Classroom Available? *

Equipment Available on Site:

Wheelchair

Wheelchair Equipped Vehicle

Stretcher/Gurney

Stretcher Vehicle

All Appropriate Safety Straps & Equipment

A copy of your responses will be emailed to the address you provided.

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