SMEMS Intermediate Pretest
Prep Course Application

This course is designed for students who will be taking the pretest within the next thirty days. Slots will be given to students with a current Intermediate application on file on a first come first serve basis.

Name:    ____________________________________________________

Address:_____________________________________________________

City:     _____________________     State: _________     Zip: _________

Phone: (H) ______________     (W) _________________

Email: __________________________________

I am applying for the following Intermediate Course:

Date: ____________     Instructor: _____________________________

I am applying for the following Pretest Prep Course:

Date: ____________

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For Office Use Only

Date Application Rec.: _____________________________________

Paid By:  Check No. ________     Cash ________     PO _________

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Please return application to:

Southern Maine EMS
496 Ocean Street
South Portland, ME 04106