NAME:    First     Last

VIRGINIA EMS CERTIFICATION NUMBER

PHONE NUMBER OTHER (Pager/cell phone)

EMAIL ADDRESS

YOUR MAILING ADDRESS:

STREET CITY STATE ZIP CODE 

EMS AFFILIATION (if any)

TEST TO BE TAKEN Select a Test First Responder EMT Basic EMT Enhanced Intermediate EMT Paramedic EMT Instructor      Initial      Recertification       Retest       Pretest       Re-entry

Is this a retest for a failed written and/or practical test?    Yes        No

If you are taking any practical skills tests, please indicate which.

TRAUMA              MEDICAL              

WHO IS YOUR PARTNER FOR SKILLS?

SELECT A SITE Select a test site 10/16/08 Page Middle School, Gloucester 12/05/08 Rappahannock Community College, Glenns 12/11/08 Newport News FD Training 01/15/09 Page Middle School, Gloucester 02/05/09 Essex HS, Tappahannock 03/19/09 Newport News FD Training 04/16/09 Page Middle School, Gloucester 05/15/09 Rappahannock Community College, Glenns 06/04/09 TBA 06/11/09 Essex HS, Tappahannock

(Applications and registration fees for skills testing must be received by the PEMS office by the Friday two weeks prior to the test date. )

Please Remember that a site may be cancelled due to an insufficient number of registrations.

YOUR INSTRUCTOR: (For Intital or Recert course candidates only)

IF SKILLS TESTING, WILL YOU BE PAYING BY CHECK OR BY MONEY ORDER ?

CHECK OR MONEY ORDER NUMBER       AMOUNT   $25        $15

Non-refundable Registration Fees where applicable are to be sent to: The Peninsulas EMS Council, PO Box 2348, Gloucester VA 23061 (Initial EMT Testing $25, Retesting one skill station $15, two stations $25.  If you are in Re-entry, Retesting, or Recertifying,  please include a copy of your eligibility letter from the Office of EMS.

Registration is not considered complete until fee is received at the Council Office.)

Please review all the information above before pressing the SUBMIT button.

By submitting this form, I affirm that I have read and I understand the Consolidated Test Registration Policies.