You are signing up to register for the EMS Case Studies with Dr. Walter and Dr. Faulk through Chautauqua County Emergency Medical Services. Please complete all of the following questions.

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* 1. Applicant's Last Name:

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* 2. Applicant's First Name:

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* 3. Best Phone Number to reach Applicant:

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* 4. Applicant's Email address:

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* 5. Applicant's Fire Department:
(LEO - choose 'Law Enforcement' and specify Department in "other")

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* 6. Applicant's Chief's Name:

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