Form C4 "Course Completion Roster Addendum" - New Hampshire

What Is Form C4?

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

Form Details:

  • Released on January 13, 2015;
  • The latest edition provided by the New Hampshire Department of Safety;
  • 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 fillable version of Form C4 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Safety.

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Download Form C4 "Course Completion Roster Addendum" - New Hampshire

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State of New Hampshire
Department of Safety
Division of Fire Standards and Training & Emergency Medical Services
Course Completion Roster Addendum
EMS I/C:
Course No.:
The following individual(s) marked as “Complete (C)” have successfully completed all outstanding requirements for this program. Those
individual(s) marked as “Fail (F)” have not met outstanding requirements and will be listed a fail for this program.
Date of
Status
(Complete
Student LEGAL Name
Mailing Address & Email Address
Phone
Status
or Fail)
Change
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
By signing this Course Completion Roster Addendum, the NH Instructor/Coordinator is attesting that each student listed as “C” (Complete) has met
all appropriate didactic, lab, clinical and field internship as per NHTSA/DOT and NHBEMS Education Standards requirements.
EMS I/C Signature:
Date:
Education Specialist Signature:
Date:
Bureau of EMS
Form C4
Date Approved: 2/25/08
Course Completion Roster Addendum
Revised:
6/09/10, 1/13/15
State of New Hampshire
Department of Safety
Division of Fire Standards and Training & Emergency Medical Services
Course Completion Roster Addendum
EMS I/C:
Course No.:
The following individual(s) marked as “Complete (C)” have successfully completed all outstanding requirements for this program. Those
individual(s) marked as “Fail (F)” have not met outstanding requirements and will be listed a fail for this program.
Date of
Status
(Complete
Student LEGAL Name
Mailing Address & Email Address
Phone
Status
or Fail)
Change
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
By signing this Course Completion Roster Addendum, the NH Instructor/Coordinator is attesting that each student listed as “C” (Complete) has met
all appropriate didactic, lab, clinical and field internship as per NHTSA/DOT and NHBEMS Education Standards requirements.
EMS I/C Signature:
Date:
Education Specialist Signature:
Date:
Bureau of EMS
Form C4
Date Approved: 2/25/08
Course Completion Roster Addendum
Revised:
6/09/10, 1/13/15