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Paramedic Request for Information

* Required for Submission

First Name*

Last Name*

Email Address*

Mobile Phone*

Birthdate*

Permanent Address*

Country

Street

City

Region

Postal Code

Affiliated Department and License Information

Department (Select all that apply)*

If you selected "Other," please enter the name of your affiliated department. If you are not affiliated with a department, enter "N/A.*

EMS License Type*

EMS License Number*