Continuing Education Training Application

 Accredited Institution 
Name of Sponsor: 
Sponsor's Phone #: 
Sponsor's Mailing Address:
Sponsor's Email:   (You must provide an email address to receive your number).
Name of Primary Instructor: 
Instructor's Phone #: 
Instructor's Affiliation and Address:
Primary Instructor's Email: 
Instructor's Certification #: 
Program Title: 
Program Type: (select the categories that apply):
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  Request Blanket Approval
Program Start Date:  8/20/2017 ]
Method Of Instruction: 
 
# Hrs Basic: 
Program End Date:  8/20/2017 ]
# Hrs Advanced: 
 
# Hrs Paramedic: 
Additional Dates and Times: 
   May EMTs outside your service contact you to enroll in this program? 
Program Address:
Additional Course Information/Notes:
  The applicant hereby affirms that they comply with, and will continue to comply with, all relevant federal and state laws, including but not limited to, federal and state anti-discrimination statutes, M.G.L. c. 111C; regulations, including but not limited to 105 CMR 170.000 and 105 CMR 700.000, and the Department’s Administrative Requirements, the Statewide Treatment Protocols, policies and advisories.

  The applicant hereby affirms that the information on this application is true and correct and that the course will conform with the standards set forth in the attached outline.

NOTE: The individual whose name appears below is the listed official representative of the applicant, and must have authority to sign all necessary program documents.

 
Please attach the following:
  
  

 

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