NAME:___________________________________________

CERT. NO.:__________________________

__________ 1. Application completed and signed.

__________ 2. Copy of most recent First Responder certification attached.

__________ 3. Copy of current CPR certification attached. Copies of both the front and back

  of the card must be sent.

__________ 4. Copy of all C.E. certificates attached.

__________ 5. Successful completion of written and skills exam.

__________ 6. Copy of picture identification attached (driver's license will suffice).

__________ 7. Application checklist completed and included with application.

__________ 8. Re-certification fee of $30.00 is enclosed or click here to pay online.

NOTE: All requirements must be met and all paperwork received in this office 15 days prior to the certificate expiration. If it is not received 15 days prior to the expiration, a $15.00 late fee will be assessed. Certification cannot be processed until all applicable fees have been paid.