STATE OF NEW JERSEY

NHTSA-EMD TRAINING PROGRAM

EMD STUDENT REGISTRATION FORM

ENTER COURSE NUMBER ISSED BY NJOETS
COURSE NUMBER

ENTER LAST NAME, FIRST NAME, MIDDLE INITIAL
NAME OF STUDENT
FIRST EMD CERTFICATION	☐	I HAVE A PRIOR EMD CERTFICATION	☐
HAVE YOU PRIVIOUSLY RECEIVED AN EMD CERTIFICATION?
ENTER NAME ON PRIOR CERTIFICATION IF DIFFERENT FROM ABOVE
PRIOR CERTIFICATION UNDER A DIFFERENT NAME	SSN
ENTER RANK OR TITLE	SSN LAST 4
RANK/POSITION/TITLE
ENTER NAME OF AGENCY SPONSORING CLASS
SPONSORING AGENCY
ENTER STREET ADDRESS, MUNICIPALITY, STATE AND ZIP
AGENCY ADDRESS	ENTER AGENCY PHONE NUMBER
ENTER COUNTY	AGENCY PHONE NUMBER
COUNTY
ENTER STUDENT HOME ADDRESS, MUNICIPALITY, STATE AND ZIP
STUDENT HOME ADDRESS (OPTIONAL)

STUDENT COURSE PRE-REQUISITE DOCUMENTATION AND RECORD OF ATTENDANCE

(TO BE COMPLETED BY LEAD INSTRUCTOR)

PRE-REQUISITE DOCUMENTATION MUST BE PROVIDED PRIOR TO A CERTIFICATION BEING ISSUED
YES	NO
CURRENT CPR CERTIFICATION (COPY ATTACHED)	☐	☐	IF NO, EXPLAIN
BASIC TELECOMMUNICATOR TRAINING CERTIFICATION (COPY ATTACHED)	☐	☐	ENTER COURSE NUMBER

NOTE: If student recently completed Telecommunicator Training and is awaiting certification, indicate the course number of that basic course.

EMERGENCY MEDICAL DISPATCH TRAINING COURSE
MODULE #1	MODULE #2	MODULE #3	LEAD INSTRUCTOR'S NAME NAME OF LEAD INSTRUCTOR
UNIT I	UNIT ``	UNIT III	UNIT I	UNIT II	UNIT III	UNIT I	UNIT II
I	I	I	I	I	I	I	I

(INITIAL COMPLETED UNITS, PLACE X IN INCOMPLETE UNITS)