KEMTIA
EMS EDUCATIONAL INSTITUTION
COURSE REQUEST FORM

After submitting this online application, send application fee (Money Order or Cashier Check ONLY), along with Instructor's Credentials to the KEMTIA Educational Institute Program Coordinator at least (3) weeks prior to the anticipated starting date of course, or at least (8) weeks prior to anticipated starting date of course if request is made for KEMTIA to schedule the instructor for the course. A full set of equipment must be available in operable condition before the course can begin.

Requested Course:
Application Fee

Continuing Education - $25, annual $10 each time after 1st change of synopsis
Course Location -    Organization Name

Contact Person

Actual Street Address

City/State/Zip

Phone

E-Mail

Requested Begin Date
Requested End Date
  Continuing Education

Complete synopsis must be attached
EMSEK Instructor Request:  
Name of EMSEK Member Available
EMSEK Instructor Needed

MAIL FEE TO:    Terri Riggle, Executive Secretary
                              EMSEK
                              4114 Handley Avenue
                              Louisville, KY 40218
                              email:  terririggle@insightbb.com