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Application for ALS Provider Clearance

Your E-Mail Address (Required)

Subject (Required)

Date

Name (Required)

Phone Number

Squad You are a Member of: (Required)

Level of Certification:

Where did you receive your ALS Training? (Required)

Other relevant training:

List 2 references who worked with you and their contact information:

Contact Information

1488 Franklin Street
Rocky Mount, VA 24151

PHONE: 540-483-3091
FAX: 540-483-3086
E-mail: Public Safety