Medium Rescue Certification 2012 V - ncarems.org

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1 Revised: 07/01/12 NORTH CAROLINA ASSOCIATION OF Rescue & EMERGENCY MEDICAL SERVICES, INC. BOX 1914, GOLDSBORO, 27533-1914 TELEPHONE: 919/736-0506 FAX: 919/736-7759 E-MAIL: CERTIFICATE OF ELIGIBILITY Medium Rescue *** PLEASE PRINT OR TYPE NAME OF DEPARTMENT______________________________ _________________________DATE___________ MAILING ADDRESS________________________________S T. ADDRESS______________________________ CITY____________________________________ ____STATE_______ZIP__________COUNTY_____ ________ DEPARTMENT EMAIL ADDRESS_________________________________ _______________________________ COMM CENTER PHONE #( )______________BUSINESS PHONE #( )_____________________________ DEPARTMENT CELL PHONE #( )___________________________FAX # ___________________________ CAPTAIN/CHIEF___________________________ EMAIL ADDRESS_________________________________ __ WORK PHONE #( )______________ HOME PHONE #( ) _____________CELL #( )________________ SECRETARY_______________________________ EMAIL ADDRESS_________________________________ __ WORK PHONE #( )______________HOME PHONE #( ) _______________CELL #( )_______________ DOES YOUR SQUAD PROVIDE?

Medium Rescue: Inspectors Initials _____ Revised: 07/01/12 3 MINIMUM STANDARD REQUIREMENTS - NCAR&EMS MEDIUM RESCUE

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