ALS Examination Registration Form

Exam information

Please refer to the ALS exams section of our website to see a current list of ALS exams.

Exam date requested:

Location: *

Level: *

AEMTIntermediate / 85Intermediate / 99Paramedic

Exam Attempt: *

InitialRetest

Previous test date:

Previous test location:

Candidate Information

Legal name: *

Address: *

City: *

State: *

Zip Code *

Home Phone: *

Cell Phone:

Email: *

Date of birth: *

Current certifications:

Current National Registry Certification: *

YesNo

National Registry number:

Expiration date:

If you do not have National Registry certification, do you hold a current State certification:

YesNo

State certification held in:

Level of certification:

Certification number:

Expiration date:

A copy of you current out-of-state certification is required, please upload a copy:

Course Information:

Course number: *

Course instructor:

Course completion date: *

Course location:

For non-New Hampshire training programs please include a copy of a letter or certifcate of completion from the State authorizing the EMS training program. Please upload a copy here:

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ALS Examination Registration Form