ccp-c program recognition application - ibsc & … care paramedic name cert type/no. _____...
TRANSCRIPT
Updated 1/2017
Program Recognition Application
Thank you for participating in the IBSC Recognition Program. Recognition by the IBSC is an acknowledgement of your commitment to high standards in the paramedic profession. By completing this form, you attest to 100% of your employed specialty Care Paramedics have one or more of the IBSC Certifications.
Company/Base Name:
Company/Base Address: (include city, state and zip code)
Company/Base Manager:
Application Submitted by (if different from above):
Phone : Email Address:
Signature: Date Submitted:
Check which size plaque you need:
12 Plate Plaque 24 Plate Plaque
IMPORTANT: Please list the names of those in your organization who have attained their CCP-C, FP-C, CP-C or TP-C, on the following page. After completing all information, click ‘Submit Application’. For any questions, contact Jeanette Myers at [email protected], or call 770-978-4400.
Submit Applicaiton
Office Use Only
Process Date: __________________
Order #: ________________________
Date Mailed: ____________________
Updated 1/2017
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
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________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.
________________________________________________________________________ Critical Care Paramedic Name Cert Type/No.