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 ___________
_________________________________ 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)).