Staff Roster Form
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1
2New Jersey Department of Health
STAFF ROSTER
Office of Emergency Medical Services
Please Print or Type
Instructions:
•
Print your services full trade name (as it appears on your vehicle and today’s date in the box below.
•
Print the full name of every person who will staff any of your vehicles.
•
Print the required information for each person, including social security number and course/expiration dates.
•
Make additional copies of this blank form as needed
Trade Name of Service (exactly as it appears on your vehicles):
Drivers
Ambulance Staff
MAV Staff
Staff Person
License
CPR
MAVT
CPR
(Last Name, First Name)
Expiration
EMT ID Number and Exp. Date
Expiration
Cert. (Exp.)
Expiration
Date
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EMS-38
JUL 12
Page 1 of 2 Pages.
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Parent category: Business