Form Doh-743 - Instructor Information Sheet - New York State Department Of Health

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NEW YORK STATE DEPARTMENT OF HELATH
Instructor Information Sheet
Emergency Medical Services Development Program
EMT Number
CLI/CIC Number
Name
Last
First & Middle Initial
Address
Street
City
State
Zip Code
County
Phone 1
Area Code
Phone 2
Area Code
Cell Phone
Area Code
E-mail
CLI
CIC
Course Taken
Certified Instructor
Update
AWR - 160 - 1
Regional Faculty
Signature
Approved
Date
DOH-743(06/09)

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