Medstar Ambulance – Northern Operations

Genesee County MCA, Oakland County MCA, and Tri-County Emergency MCA

First Name*

Last Name*

First Name Required Last Name Required

Email:* Email is Required

License Type:* License Type is Required

State Issued:* State Issued is Required

EMS License Number (State issued; Required for CAPCE and State CE): EMS License Number (State issued; Required for CAPCE and State CE) is not valid

EMS License Date of expiration (Required with State EMS License #): EMS License Date of expiration (Required with State EMS License #) is not valid

NEMSID (12-Digit National EMS ID #): NEMSID (12-Digit National EMS ID #) is not valid

NREMT Registry Number (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 a Registry #.): NREMT Registry Number (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 a Registry #.) 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: State of Residence is not valid

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

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