Form EMS-56 "Application for Certification as an Emergency Medical Technician-Basic Instructor" - New Jersey

What Is Form EMS-56?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form EMS-56 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form EMS-56 "Application for Certification as an Emergency Medical Technician-Basic Instructor" - New Jersey

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New Jersey Department of Health
Office of Emergency Medical Services
P. O. Box 360
Trenton, NJ 08625-0360
APPLICATION FOR CERTIFICATION AS AN
EMERGENCY MEDICAL TECHNICIAN-BASIC INSTRUCTOR
DEMOGRAPHICS
Name
Social Security Number
Date of Birth
Mailing Address
(Required for OEMS Use Only. Must be a physical address; no PO Box or Mail
Stop numbers accepted.)
Home Telephone Number
City
State
Zip Code
Work Telephone Number
Public Address
(Optional - the Department will provide this address for requests of government
records.)
Cell Phone Number
City
State
Zip Code
Email Address
AFFILIATION
EMT Course Affiliation
Course Coordinator
Coordinator Contact Number
Level of Certification
Certification Number
EXPERIENCE
Years Certified
Years EMS Experience
Total Teaching Time as Aide
Total Teaching Hours
EDUCATIONAL BACKGROUND
School
Dates
Graduated
Major
High School
College
Graduate
Other
I verify that all of the above information and attached supporting documentation is correct and factual. I understand that any
discrepancies may be cause for disqualification from the EMT Instructor candidate screening process.
Signature
Date
NOTE: Please include a copy of your resume, coordinator letter of recommendation, and two additional letters of recommendation
with this application.
EMS-56
JUL 12
New Jersey Department of Health
Office of Emergency Medical Services
P. O. Box 360
Trenton, NJ 08625-0360
APPLICATION FOR CERTIFICATION AS AN
EMERGENCY MEDICAL TECHNICIAN-BASIC INSTRUCTOR
DEMOGRAPHICS
Name
Social Security Number
Date of Birth
Mailing Address
(Required for OEMS Use Only. Must be a physical address; no PO Box or Mail
Stop numbers accepted.)
Home Telephone Number
City
State
Zip Code
Work Telephone Number
Public Address
(Optional - the Department will provide this address for requests of government
records.)
Cell Phone Number
City
State
Zip Code
Email Address
AFFILIATION
EMT Course Affiliation
Course Coordinator
Coordinator Contact Number
Level of Certification
Certification Number
EXPERIENCE
Years Certified
Years EMS Experience
Total Teaching Time as Aide
Total Teaching Hours
EDUCATIONAL BACKGROUND
School
Dates
Graduated
Major
High School
College
Graduate
Other
I verify that all of the above information and attached supporting documentation is correct and factual. I understand that any
discrepancies may be cause for disqualification from the EMT Instructor candidate screening process.
Signature
Date
NOTE: Please include a copy of your resume, coordinator letter of recommendation, and two additional letters of recommendation
with this application.
EMS-56
JUL 12