CEU-EMT.com Secure Sign-up Form

Membership Type *	Airway Management Module 2 ($9.95 for 5 years) Airway Management Module 2 - EMT- Basic, 2 Continuing Education Hours Accredited by CECBEMS.
Payment System *	PayPal Secure and Convenient Payment Secure Credit Card Visa, Mastercard and Amex
Your Name * Your First & Last name
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 6 or more characters in length and may only contain small letters, numbers, and the underscore '_'
Choose a Password * Must be 6 or more characters
Confirm your password * Enter password again
EMT License Type * What level of licensure do you currently hold?
State of EMT Licensure * Do you have a state EMT License? If so please choose your state. (If you only have NREMT certification choose "National Registry Only".
State License Number * Do you have a State EMT License? If so, Please enter it here. (Required for reporting of state Continuing Education Credit)
State License Expiration Date If you have a state license, what date does that license expire? (Required for reporting of state CE credit)
NREMT Certification Number * Are you NREMT Certified? If so please enter your certification number here. This will ensure that you get proper Continuing Education credit with the NREMT.
NREMT Expiration Date * If you are NREMT certified,what date does your certification expire? (the date is on your card, please enter as mm/dd/yyyy)
Phone Number * Please enter your phone number (* Required by CECBEMS)