Class Registration Form

You may pre-register for the classes at the EMS Academy. In order for your registration to be confirmed. you will need to mail an original copy of the training fund form or payment to the MICU office.

Please provide the following contact information:

First Name
Last Name
Address
City
State	NJ Pa De
Zip
Home Phone
Soc Sec Number
FAX
E-mail

Please list the classes below:

        I Qualify for Volunteer OEMS Funding  none Yes No

Date	Class

	Billing  Information
Training Fund	Payment to Follow	Payment Bill Agency
	Purchase Order #
	Account Name

Please Print this form and Mail it to :

                                EMT CEU Classes

                                UMH MICU

                                238 S Evergreen Ave

                                Woodbury, NJ 08096