CARS Form

* - denotes required fields
* EMS Agency/Hospital requesting change:		Field 'EMS Agency/Hospital requesting change' is blank	* Contact Person:		Field 'Contact Person' is blank
* Contact Phone:		Field 'Contact Phone' is blank	* E-mail:		Field 'E-mail' is blank

To ADD EMT-Bs

Name: EMS Agency: -- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department Address:	DOB: Date Field 'DOB' is invalid SS#: DL#: EMT-B License #: Exp: Date Field 'Exp' is invalid
Name: EMS Agency: -- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department Address:	DOB: Date Field 'DOB' is invalid SS#: DL#: EMT-B License #: Exp: Date Field 'Exp' is invalid
Name: EMS Agency: -- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department Address:	DOB: Date Field 'DOB' is invalid SS#: DL#: EMT-B License #: Exp: Date Field 'Exp' is invalid

To ADD AN EMT/PHRN/ECRN already working in the System at another Agency/Hospital:

Name:			EMS License #:			Current agency:	-- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department
Name:			EMS License #:			Current agency:	-- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department
Name:			EMS License #:			Current agency:	-- select -- Advance Ambulance Advantage Ambulance Inc. Arlington Heights Fire Department Barrington Fire Department Bloomingdale Fire Protection District #1 Buffalo Grove Fire Department Des Plaines Fire Department Elk Grove Township Fire Department Elk Grove Village Fire Department Fermilab Hoffman Estates Fire Department Itasca Fire Department Lake Zurich Fire Department Lincolnshire Riverwoods Long Grove Fire Department Mt. Prospect Fire Department NWC EMSS EMT-P Students NWC EMSS Staff Palatine Fire Department Palatine Rural Fire Department Prospect Heights Fire Deprtment Rescue Eight Paramedic Services Rolling Meadows Fire Department Roselle Fire Department Schaumburg Fire Department Schiller Park Fire Department Superior Ambulance Service Wooddale Fire Department

To DELETE an EMT/PHRN/ECRN or person with administrative access.

Name:			EMS License #:			Date to delete:		Date Field 'Date to delete' is invalid
Name:			EMS License #:			Date to delete:		Date Field 'Date to delete' is invalid
Name:			EMS License #:			Date to delete:		Date Field 'Date to delete' is invalid

Administrative Access Addition/Change

Name:			User Level:		Field 'User Level' is invalid	Passcode request:
Name:			User Level:		Field 'User Level' is invalid	Passcode request:
Name:			User Level:		Field 'User Level' is invalid	Passcode request:

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