Submit EMS Continuing Education Hours for Approval

Requesting Agency *

Requestor's Name *

Requester's Email *

Mailing Address *

City *

State * - Select a State - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Course Title *

Core Topic(s) *

• Airway
• Cardiac
• Medical
• Trauma
• Operations

If more than one Core Topic was selected, please indicate how much time will be spent on each topic

Course Objectives (minimum of 2 objectives per hour of course) *

Course Date *

Course Start Time *

Course End Time *

Course Location *

Total Course Hours *

Will this course be offered on multiple dates and times. If yes, please list all dates and times.

I understand that my agency must have a signed affiliation agreement and I understand the terms of the affiliation agreement. *