PRINT THIS PAGE TO MAIL IN TO US, PLEASE FILL IT OUT
COMPLETELY FOR US TO PROCESS YOUR APPLICATION.

Enclose your CHECK or MONEY ORDER made payable to EMT-TA

Save a stamp and pay with your paypal account www.PayPal.com
Our email payment address for this option is emtta@comcast.net

Mail your registration form and fee to:
EMT TRAINING ASSOCIATES
P.O. BOX 994
SAUGUS, MASS 01906-0194

IF CANCELLATION IS NECESSARY ON YOUR PART, IT MUST BE DONE NO LATER THAN 72 HOURS PRIOR TO THAT PROGRAM IN ORDER TO RECEIVE ANY REIMBURSEMENT.
ALL REFUNDS ARE SUBJECT TO A $15.00 SURCHARGE - **NO EXCEPTIONS**

* PLEASE CIRCLE YOUR SELECTION *

DOT REFRESHER COURSE - Caritas, St. Elizabeth's
November 7th, 8th, and 14th 2009
***EARLY BIRD SPECIAL***
Must be postmarked & rec'd by 9/30 - $60.00
Postmarked 10/1 through & Rec'd by 10/26 - $70.00
Rec'd AFTER 10/26 & ALL Walk-Ins - $85.00

CON-ED 6 HOURS - Caritas, St. Elizabeth's Saturday September 12th 2009
Must be postmarked & rec'd by 09/09
$45.00 for 6 Hours
Walk-Ins will pay a $10.00 fee in addition to the above rate.

CON-ED 8 HOURS - Caritas, St. Elizabeth's Saturday October 3rd 2009
Must be postmarked & rec'd by 09/30
$55.00 for 8 Hours
Walk-Ins will pay a $10.00 fee in addition to the above rate.

PLEASE PRINT NEATLY THE FOLLOWING INFORMATION:

NAME:

EMT NUMBER:

PHONE NUMBER:

ADDRESS:
CITY/STATE/ZIP:

TOTAL AMOUNT ENCLOSED: