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1. Full Name (Required.)

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2. Phone Number (Required.)

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3. Email Address (Required.)

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4. Department/Agency (If affiliated) (Required.)

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5. Are you already a KY licensed EMT? (Required.)

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6. If yes to question 5, when did you complete the course?

Date

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7. If you would like to attend, however feel you have concerns that may limit your eligibility/ability to complete the course, Please explain below.

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