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:_________________________ County:___________________________

 _________________________________ 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)).