CEU-EMT.com Secure Sign-up Form

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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? This is required for reporting of state CE credit. (the date is on your card, please enter as mm/dd/yyyy)
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)
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