Thank you for expressing an interest in registering your program with EMSBooks.com. Please complete the following application to enable us to collect the materials, prepare your program's package deal and submit it for your approval.

Completing this application in no way commits you to participate in the program, but simply gives us accurate information to prepare a product to you for final approval before being presented to our visitors.

* Your Name:

* Your Email:

* Phone No.:

* School's or Institution's Name:

* Program's Name (ie. ABC's Paramedic Program):

Brief Description:

Does your school or institution have a website?
No Yes - (provide address)

Is there a graphic that you would like associated with your program(s)?
No Yes - (provide url)
(if you do not know the url for the graphic, you may email it to kathy@emsbooks.com)

* Required Textbooks:
List all required textbooks.
(Be sure to include the Title, ISBN, Publisher, and Author.)

Optional Textbooks:
List any optional textbooks.
(Be sure to include the Title, ISBN, Publisher, and Author.)

Do you have any additional information, materials or services that you desire to have provided to your students (workbooks, software, etc.)?
No Yes - describe:

Are there any other materials that your students are required to have (pocket masks, scissors) that we may be able to add to your student's packages?
No Yes - please list:

Class Start Date:

Estimated Enrollment:

Additional Notes/Comments: