ࡱ> >@={`  #bjbjFF *,,,48(DLLew K      $yhD9eeD}KK =1t0DDLLLLLL New Jersey Department of Health and Senior Services Office of Emergency Medical Services EMT TRAINING FUND CERTIFICATE OF ELIGIBILITY FOR AN EMT BASIC COURSE Name of Student: FORMTEXT      Volunteer EMS Agency: FORMTEXT      Address: FORMTEXT      County: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Course Sponsor: FORMTEXT      Course Start Date: FORMTEXT      The undersigned verifies that: 1. All of the information above is true and accurate. 2. The EMT listed above is a member or a 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. 3. All monies paid for training will ONLY be made to the basic course sponsor. Verified by: Name of Principal Officer (Print): FORMTEXT < ^ ` t v x     ( * > @ B L N ^ ` t v x ܼܼܼܼܼqj hI5CJUjhI5CJUjdhI5CJUjhI5CJUjhI5CJU!jhI5CJUmHnHujhI5CJUjhI5CJU hICJ hICJhI hI5CJ,h< ^ Kkdt$$IfTH 0x' 4 HaT $If^$If$a$ "#  ( P h$If`h $If^$IfKkdl$$IfTH0('p4 HaTP R ^ {q{q{ h$If`h $If^$Ifqkd$$IfTH\`'@ 4 HaT   & ( * 4 6 ` b v x z  h i s t    4 6 8 B D F | ~ շըܤܤՕՄjhI5CJUUjhI5CJUhIjhI5CJUjhI5CJUj~hI5CJU hI5CJ hICJjhI5CJU!jhI5CJUmHnHu/  8 gaU $If^$Ifkd$$IfTHֈp'88p4 HaT8 : ` ?;XakdV$$IfTH4F'@     4 Haf4T $If^$IfKkd^$$IfTH0'00!4 HaT  8 E h    F `Nkdj$$IfTH4 0 '@  4 Haf4T $If^$Ifx T[xX]^[` T[x^[` T[x]^[`      Title: FORMTEXT      Contact/Telephone Number: FORMTEXT      Signature of Principal Officer:Date: FORMTEXT      NOTICE: It is a crime for any person knowingly or willfully to provide false information on this application, or make deliberately misleading statements regarding the eligibility of applicants [N.J.S.A. 2C:21-4(s)].     EMS-80 AUG 03 F H | OD  !$IfNkdf $$IfTH40 ' 4 Haf4T $If^$IfNkdh $$IfTH40'$4 Haf4T ! !!!!!!,!"""""""""# #ʹǯççççjhIU hI5j hI5CJUhI hICJ hI5CJ!jhI5CJUmHnHujhI5CJUj hI5CJU !!""""""""wdbbbbbbb$]^`a$qkdd $$IfTH\ p' 8p4 HaT $If^ h$If`h """### #$]^`a$(/ =!8"8#8$8%88 tDText1$$If!vh55 #v#v :V H ,55 / 44 HTtDText1$$If!vh5p5#vp#v:V H,5p5/ 44 HTtDText1tDText1$$If!vh5555@ #v#v#v#v@ :V H,5555@ / / 44 HTtDText1tDText1tDText1$$If!vh55585585p#v#v#v8#v#v8#vp:V H,55585585p/ / / 44 HTtDText1$$If!vh5050!#v0#v0!:V H,5050!/ 44 HTtDText1$$If!vh55@ 5#v#v@ #v:V H4,55@ 5/ 44 Hf4TtDText1$$If!vh5@ 5 #v@ #v :V H4 ,5@ 5 / 44 Hf4TtDText1$$If!vh55$#v#v$:V H4,55$/ 44 Hf4TtDText1$$If!vh5 5#v #v:V H4,5 5/ 44 Hf4TtDText1$$If!vh5 5585p#v #v#v8#vp:V H,5 5585p/ / 44 HT@@@ NormalOJQJ_HmH sH tH >@> Heading 1$$@&a$5F@F Heading 2$$@&a$5CJDAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List DT@D Block Text]^CJ4@4 Header  !4 @4 Footer  !, z4Yk ()/CJ^cwx8Eh|}`'s`'s`'s`'s0j sj`sBTj s8j sBT@j sjsjsBTj sBTxj sjBT`'j`'j`'j`'j`'j js@j$sBTH jsBTH jPv:jsBT`'j`'j`'j4Yk ()/CJ^cwx8Eh|}y0y0y0y0y00y0y0y0 y0 y0 y0 y0 y0 y0 y0 y0 y0 y0 y0 y0y0y0y0y0y0y0y0y0y0#y0%y0%`y0(y0(y0+y0+y0+y0+`k''y0y0y0y0y0y0y0y0y0y0y0y0y0  #  P 8 F " # #   &/;AJV\couhtzFTFTFTFTFTFTFTFTFTFTFTFTFT8@0(  B S  ?Text1Ik ()/CJ^cwx8Eh|} j ( &Quickword QuickwordCustom Popup 2760539%Y\jCustom Popup 2760539 Custom Popup 27605390(&Open...&Open...DoOpen(&Save&SaveCES_Save( Save &As... Save &As... CES_SaveAs(&Help&HelpDoHelp(Abou&tAbou&tDoAbout@ ''4u`` `@` UnknownGz Times New Roman5Symbol3& z Arial"h&&[x&$$ٖ4#~4d+3HX(?I29EMS-80 Certificate of Eligibility for an EMT Basic CourseEWhite Bill VoelkelOh+'0 4@ ` l x <EMS-80 Certificate of Eligibility for an EMT Basic CourseEWhiteBasictrngformBill Voelkel2Microsoft Office Word@@\?%`@h{=1@h{=1$՜.+,0$ hp  NJDHSSG :EMS-80 Certificate of Eligibility for an EMT Basic Course Title  !"#$%&'()*+,./012346789:;<?Root Entry Fp,'=1AData 1TableWordDocument*,SummaryInformation(-DocumentSummaryInformation85CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q