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EMS/FIRE/LAW Enforcement Affiliation Form
Please fill out this form completely to include the course you are registering for. Be sure to check, read and verify the "Certification of Accuracy" below prior to submitting this form electronically. Affiliations will be verified by phone. Incomplete Affiliations will not be accepted.
First Name *
Middle Name
Last Name *
Email *
Phone Number *
Address *
City *
State *
Zip *
Course title student is requesting registration *