This enrollment form is for the agency administrator(s) only. Personnel are added by the administrator.

First Name:* First Name Required

Last Name:* Last Name Required

Email:* Email is Required

License Type (Select From Dropdown Menu):* License Type (Select From Dropdown Menu) is Required

EMR/MFREMTEMT-BEMT-IntEMT-PParamedicPCPAEMTCFROther

State Issued (Select From Dropdown Menu):* State Issued (Select From Dropdown Menu) is Required

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther

State EMS # (Required for CAPCE and State CE): State EMS # (Required for CAPCE and State CE) is not valid

Date of expiration (Month day, year)(Required with State EMS #): Date of expiration (Month day, year)(Required with State EMS #) is not valid

NREMT # (Leave BLANK if none. This means, do not put any abbreviations or words in this field. Simply leave the field empty if you do not have an NREMT number.): NREMT # (Leave BLANK if none. This means, do not put any abbreviations or words in this field. Simply leave the field empty if you do not have an NREMT number.) is not valid

NREMT Re-registration Date (Required if NREMT # is provided): NREMT Re-registration Date (Required if NREMT # is provided) is not valid

Agency Name (Providing the agency name does not automatically enroll you in the agency account.): Agency Name (Providing the agency name does not automatically enroll you in the agency account.) is not valid

Your City of Residence:* Your City of Residence is Required

State of Residence (Select From Dropdown Menu): State of Residence (Select From Dropdown Menu) is not valid

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginaWashingtonWest VirginiaWisconsinWyomingNone

Zip Code:* Zip Code is Required

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength  Password must be "Medium" or stronger

This site collects names, emails and other user information and never sells user information. By agreeing to this policy, you consent to the terms set forth in the Privacy Policy. If you are taking CAPCE accredited courses, you additionally understand that American CME will submit a record of your CAPCE course completions to the CAPCE AMS. You further understand that course completion records may be accessed by or shared with such regulators as state EMS offices, training officers, and NREMT on a password-protected need-to-know basis. In addition, you understand that you may review your record of CAPCE accredited course completions by contacting CAPCE.

 

No val Please fix the errors above