CEU Class Submission Request

Class Information

Name*
Full
Email*
Is this a new or existing client?*
- New
- Existing
Is this a new or existing class?*
- New
- Existing
Is this this class multiple days?*
- Yes
- No
Is this class open to the public?*
- Yes
- No
Number of Students Allowed*
Amount of CEUs to be applied for*
Amount to be charged to client*
Pay Information
Pay is as follows:

EMT Instructor - $250.00 Per Day

EMT Aide - $200.00 Per Day

2 CEU Class - $75.00 Per Class

3 CEU Class - $100.00 Per Class

Travel Time (If greater than 30 minutes) - $20.00 Per Hour (Paid in quarter hour incriments)
Special Instructions
I.e. Wifi information, etc.
Name
This field is for validation purposes and should be left unchanged.