2. Group Information
4. Group Name
6. Address 1
8. Address 2
10. City
11. State
12. Zip
14. Local Contact Person
15. Local Contact Email
17. Local Contact Day Phone
18. Local Contact Evening Phone
22. Course Information
24. Course Title
25. Course Code
26. Course Hours
28. Course Start Date (MM/DD/YYYY)
29. Course End Date (MM/DD/YYYY)
31. Course Location
32. Course Start Time
33. Course End Time
35. Proposed Instructor
36. Has the instructor been contacted?

    1. Yes
    2. No
38. Does your group's insurance carrier provide accident insurance and worker's compensation coverage for the participants?

    1. Yes
    2. No
40. Is this course DOH Continuing Education eligible?

    1. Yes
    2. No
41. If yes, what are the number of hours?
43. Level of Program

    1. ALS
    2. BLS
    3. Both
45. DOH Continuing Education Pre-Approved

    1. Yes
    2. No
46. If yes, DOH CE number(s):
48. DOH Continuing Education Applied for By

    1. CCAC
    2. Sponsoring Institution
    3. Instructor
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50. 1. Receive an email copy of this form.
51. Email address

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