EMR Recertification Course Registration

Student Information
Name*
First Last
Email Address*
Course instructions will be emailed to this address, and it will also become your username for logging into the online course.
Enter Email Confirm Email
Alternate Email Address
If you sometimes use another email address, please enter it here.
Enter Email Confirm Email
Phone Number*
Just in case we can't reach you by email.
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Certification Info
EMR 16 Hour NCCP Course
Select type of recertification*
Expiration date of your NREMT certification*
You must complete recertification training before your expiration date.
MM slash DD slash YYYY
Enter your national registry number
Log in to your NREMT account here to find your registry number. It is a letter followed by seven numbers (for example: A12345678). If you cannot find this number now, you will just need to send it to us before completing the course.
Enter your 12 digit NREMT EMS ID
This is the new 12 digit number assigned to all NREMT-certified personnel also found within your NREMT account. If you cannot find this number now, you will just need to send it to us before completing the course.
Select renewal State*
Expiration date of your state EMR certification/license*
MM slash DD slash YYYY
Enter your State EMR certification/license number
If you cannot find this number now, you just need to send it to us before finishing the course.
Are you a licensed Peace Officer?*
This course qualifies for POST credits.
POST license number
This field only applies if you are a licensed Peace Officer that would like to receive POST education credits for this course.
BLS Certification
The Minnesota EMS Board highly recommends EMRs maintain BLS certification (CPR for Healthcare Providers), and it's also required by most employers. We provide a BLS course for those who need it.
BLS Classroom Session*
A classroom session is required to practice and test out on your skills at our EDINA facility (7405 Bush Lake Road, 55439).
Anything else you'd like us to know?
Payment
Discount Code
Northwestern Health Verification*
- I verify that I am currently a student or faculty/staff member of Northwestern Health Sciences University.
Total
$0.00
Payment Method*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Invoice to a Sponsoring Organization
Did your organization give you a code to enter when registering?*
Organization ID Code*
Enter the code below
Name of Organization*
Contact Person at Organization*
First Last
Phone of Contact Person*
Email of Contact Person*
Enter Email Confirm Email
Mailing Address of Organization*
Street Address Address Line 2 City State ZIP Code
Instruction for Submitting Invoice
Enter any specific instructions we should know about submitting an invoice to this organization (for example: what to include in the memo, etc).
Agreement & Signature
Invoice Terms and Conditions*
- I understand and agree that the organization above has authorized payment for my course fees.
Verification of EMR Certification/License*
- I verify that my EMR certification/license is valid and has NOT expired, and I have sufficient time to complete the recertification training before my certification/license will expire.
Lapsed EMR Certification/License*
- I verify understanding that I must complete the entire 16 hour recertification training by October 31 (within one year of expiration) to be eligible to regain EMR certification.
Terms and Conditions*
- I understand and agree to the TERMS AND CONDITIONS
Signature of Student*
By typing my first and last name below, I verify understanding and agree to the terms and conditions. I also verify that the person completing this form is the student enrolling in the course.
First Last

EMR Recertification Course Registration

Student Information

Certification Info

Payment

Invoice to a Sponsoring Organization

Agreement & Signature