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Educational Institution Select Educational Institution National Emergency Training Network Medical Systems Tidewater Community College My program is not listed. I am challenging the examination from out-of-the-region.

I would like to take the ALS Written examination on the following date:

Month Select a Month January February March April May June July August September October November December Day Select a Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Time Select a Time 9:00 a.m. - 11:00 a.m. 1:00 p.m. - 3:00 p.m. 2:00 p.m. - 4:00 p.m.

I am a candidate for the following certification level:  Please Select a Level Cardiac Technician Intermediate Paramedic

Have you taken the ALS Written Examination within the past year?  Please Select One Yes No

How many times have you taken the ALS Written Examination within the past year?  Select an Answer I have not taken this Examination previously. 1 2 3 4 More than 4

You are confirmed upon submission of this form.  You will not be contacted by a staff member. 

Did you complete your Initial ALS Course within the past 12 months?  Please Select One Yes No

Did you complete your Initial ALS Course within the past 6 months?  Please Select One Yes No

Have you successfully completed the National Registry Intermediate/Paramedic practical

 within the past 2 years?   Yes    No