Northwest Region Prehospital Care Program

This form is intended to be completed by paramedics requesting an extension of their certification year because of being unable to complete all their Maintenance of Certification requirements by the required due date.

Name(*)

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Email(*)

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EHSN#(*)

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Reason you are requesting an extension

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What date will you complete your recertification requirements?

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For Office Use Only

Reviewed by

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Approved

YES
NO Invalid Input

Certification date extended to:

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Notes/Comments

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Certification Extension Request Form

For Office Use Only

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