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TLC Emergency Medical Services 160 Homer Ave Cortland, NY 13045 (607) 756‐8389 APPLICATION FOR CFR OR EMTBASIC TRAINING Name: Address: Telephone: Cell – – Home – – Work – – E‐Mail Address: Current Level: CFR EMT‐Basic New Course Type Applying For: CFR Original CFR Refresher EMT‐Basic Original EMT‐Basic Refresher Course Location: Course Start Date: EMS Affiliation: Please indicate your primary EMS affiliation, if any Please note: A student who is a volunteer or municipal employee of an emergency medical service may be eligible for tuition support by the New York State Department of Health. Tuition support can only be provided for members of EMS Agencies that have an EMS Agency Code. Tuition support can only be provided for students who pass the state (re)certification exam. For a reservation, complete and return this form either by mail or fax to: TLC EMERGENCY MEDICAL SERVICES 165 North St Auburn, NY 13021 FAX: (315) 2521109 For questions, please contact our offices at (607) 756‐8389 or (315) 252‐1106 Last First MI Street City State ZIP