ࡱ>  7 bjbjUU -(7|7| lDDD8|,`0:jjjMD5T$T tv9 Mjj;XjjUj @^D;$n0Atlantic Ambulance EMS Training Center Presents: Overlook Hospital EMS Dinner/ Stroke Presentation 2 Elective CEUS December 8th, 2005 Class begins promptly at 18:00hrs. Dinner will begin at 18:30hrs (Individuals arriving more than 15 minutes after the start of class will NOT be eligible for credit) Overlook Hospital - Wallace Auditorium 99 Beauvoir Ave Summit, NJ 07902 INSTRUCTOR: William Atkinson, RN, BSN, MA Non-affiliated EMTs: Fee FREE PRE-REGISTRATION IS REQUIRED! Please complete bottom portion of this form and return with completed certificate of eligibility portion or payment to: Atlantic Ambulance EMS Training Center P.O. Box 220 Internal Box 256 Summit, NJ 07902 Fax: 908-522-5394 PLEASE PRINT: Name:  FORMTEXT       Address: FORMTEXT       Town/Zip:  FORMTEXT       Day Phone:  FORMTEXT       SS#:  FORMTEXT       Date of Birth:  FORMTEXT       Affiliation:  FORMTEXT       Email Address:  FORMTEXT        FORMCHECKBOX  Add to our Email Mailing List (otherwise, emails sent for this class only) Office Use Only: Cert. of Elig: ________ Ck #:__________ Amt: $__________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Volunteers eligible for NJ EMT Training Fund must have the following completed: EMT Training Fund Certificate of Eligibility Students Name:  FORMTEXT  Ref Name    Volunteer EMS Agency: FORMTEXT  Ref Affiliation    Address:  FORMTEXT  Ref Address    County:  FORMDROPDOWN   FORMTEXT  Ref TownZip    Course Site: Atlantic Health Systems ID Number: FORMTEXT  Ref SS    Course Start Date: 10/13/2005 The undersigned verifies that: All of the information above is true and accurate. The EMT student listed above is a member or perspective member of a volunteer ambulance, first aid, or rescue squad and is eligible for reimbursement of EMT training expenses in accordance with NJAC 8:40A.. Verified by:__________________________________ Title:__________________________________ (Principal Officers Signature) Principal Officers Name (PRINTED):_____________________________________________________ NOTICE: It is a crime for any person to knowingly or willfully provide false information on this application, or make deliberately misleading statements regarding the eligibility of applicants. (NJSA 2C:21-4(a)).     Page  PAGE 2 of  NUMPAGES 1  EMBED Word.Picture.8  Atlantic Ambulance EMS Training Center (P.O. 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