CMTI EMT-A

Do you have access to a laptop?
Which Class are you registering for?
Are you a Brewster Ambulance employee?*

YesNo
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Social Security
Date Of Birth
Email Address
High School Attended
Graduated

YesNo
College Attended
Graduated

YesNo
Do you currently have health insurance?

YesNo
Have you ever been convicted of a felony?

YesNo
Have you ever been convicted of any offense relating to controlled substances?

YesNo
If you answered yes to either of the questions above, please explain:
Work History
Current Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Case Of Emergency
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Affirmation
I certify, that the information provided in this application, is correct and complete. I understand that any omission or falsification of information is grounds for exclusion and dismissal. If accepted into the program, I agree to meet all entrance requirements and to confirm and abide by the letter and spirit of the rules, regulations, and procedures of CMTI, Inc.
Type full name
Date

MonthDayYear
Program Fee
Total Fee: $1500.00 (Includes textbook and online learning system)

The total fee is due in full by the first day of class unless financing has been approved. The initial deposit* is non-refundable and MUST accompany the application when applying.

*Initial Deposit: $250.00 -- Seats are filled in the order that deposits are received. It is IMPORTANT that you return your application and deposit as soon as possible to reserve your seat in class.

* Certification exam fees are not included in the tuition
Program Fee
prevnext( X )
Initial Deposit$250.00

Total Fee$1,500.00
Should be Empty:

Work History

In Case Of Emergency

Affirmation

Program Fee