STATE OF NEW JERSEY

PUBLIC SAFETY TELECOMMUNICATOR TRAINING

EMD CLASS REGISTRATION FORM

DATE: Click here to enter a date.

SELECT TYPE OF EMD COURSE	☐	☐
FULL 32 HR	RECERT 24 HR

ENTER LAST NAME, FIRST NAME, MI.
NAME OF LEAD INSTRUCTOR
ENTER RANK OR TITLE	Date	LAST 4 ONLY.
RANK/POSITION/TITLE	INSTR CERT DATE	SSN (LAST 4)
ENTER NAME OF AGENCY SPONSORING CLASS.
SPONSORING AGENCY
ENTER STREET ADDRESS, MUNICIPALITY, STATE, ZIP.
AGENCY ADDRESS
ENTER NAME OF COUNTY.	PHONE NUMBER.
COUNTY	AGENCY PHONE NUMBER
ENTER INSTRUCTOR’S E-MAIL ADDRESS, (MAY ENTER MORE THAN 1).
E-MAIL ADDRESS

ENTER NAME OF INSTRUCTOR (LAST, FIRST, MI).
ENTER NAME OF INSTRUCTOR (LAST, FIRST, MI).
ENTER NAME OF INSTRUCTOR (LAST, FIRST, MI).
LIST NAMES OF ADDITIONAL INSTRUCTORS

CLASS INFORMATION

FIRST DAY OF CLASS.	LAST DAY OF CLASS	ENTER NUMBER OF STUDENTS IN CLASS
CLASS BEGINS	CLASS ENDS	NUMBER OF STUDENTS
NAME OF FACILITY,ADDRESS, MUNICIPALITY, STATE AND ZIP
CLASS LOCATION
PHONE NUMBER OF FACILITY	COST PER STUDENT	YES ☐ NO ☒
CONTACT PHONE NUMBER	COURSE FEE	OPEN TO OUTSIDE STUDENTS
LIST MATERIALS NEEDED FROM OETS.	PICK-UP ☐ MAIL☒
MATERIALS NEEDED FROM OETS	DELIVERY
ANY ADDITIONAL INFORMATION
SPECIAL INSTRUCTIONS

OETS ASSIGNED COURSE NUMBER