New Jersey Department of Health and Senior Services
Office of Emergency Medical Services
EMT Training Fund Certificate of Eligibility Form
Student's Name___________________ Volunteer EMS
Agency
___________
Address:
_________________________________
Course Site: _______________________
I.D. Number_______________________
Course Start Date: __________________
The undersigned verifies that:
1. All of the
information above is true and accurate.
2. The above mentioned is a member or prospective member of a
volunteer
ambulance,
first aid or rescue squad and is eligible for reimbursement of
EMT training
expenses in accordance with N.J.A.C. 8:40A.
Verified by: ___________________________
Title: __________________________
(Principal Officer's Signature Captain or
President)
Principal Officer's Name (PRINTED):
_______________________________________
NOTICE :
It is a crime for any person knowingly or willfully to provide false information
on this application, or make deliberately misleading statements regarding the
ability of applicants(NJSA 2C:21-4(a)).