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| Marion County EMS 202 S 3rd St, Ste B Marion, KS 66861-1659 620-382-3271 |
| PLEASE TYPE OR PRINT |
| Sponsoring Organization: |
MARION COUNTY EMERGENCY MEDICAL SERVICE |
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| Program Managers Name: |
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Phone: |
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| Address: |
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City: |
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State: |
KS |
Zip: |
66861 |
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| Medical Director: |
Shauna Kern, D.O. |
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| Class Location, Building: |
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Address: |
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| City: |
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State: |
Ks. |
Zip: |
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EMS Region III |
| This program is open to attendants outside of your agency? |
Yes |
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No |
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| Is this class submitted for educational incentive grant funding? |
Yes |
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No |
x |
| Complete the schedule on the back of this form and must be received at least 15 days prior to |
| beginning the continuing education program. If there are any schedule changes necessary, |
| notify Marion County EMS in writing. |
| THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF |
| MY KNOWLEDGE. |
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| Signature of Applicant |
Date |
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| Marion County EMS Use Only |
| This proposed schedule: |
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is approved |
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is not approved |
| Course Identification Number: |
#PP-3271 |
| Amount of continuing education credit awarded: |
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| Approved by |
Date |