Associates in Emergency Care

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AEC EMS Course Registration

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If for any reason you need to cancel your registration and payment, please contact our office as soon as possible. Advanced cancelations and class transfers will incur a $25.00 fee. Same-day cancelations or no-shows will be subject to forfeiture of all fees paid.

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By submitting this form, you agree to pay Associates in Emergency Care the amount indicated below.

First Name	Last Name	Daytime Phone Number
		Evening Phone Number
Street Address	City or Town

State	Zip Code

Email Address	Location and Start Date of Course	EMT-B Refresher EMT-Basic EMT-Intermediate EMT-Paramedic ITLS PEPP GEMS


Card Type
Name as it appears on card	Card Number	Amount to Charge

Security Code CVV2	Expiration Date
Billing Address Same As Above? Leave Blank If Same As Above

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