CARS Request

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Home : CARS Request

Northwest Community EMS System

CARS Program
Personnel Password/Change Request Form

* - denotes required fields
* EMS Agency/Hospital requesting change:		* 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:
Address:

DOB:

SS#:

DL#:

EMT-B License #:

Exp:

Name:
EMS Agency:
Address:

DOB:

SS#:

DL#:

EMT-B License #:

Exp:

Name:
EMS Agency:
Address:

DOB:

SS#:

DL#:

EMT-B License #:

Exp:

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

Name:	EMS License #:	Current agency:
Name:	EMS License #:	Current agency:
Name:	EMS License #:	Current agency:

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

Name:

EMS License #:

Date to delete:

Name:

EMS License #:

Date to delete:

Name:

EMS License #:

Date to delete:

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:

Northwest Community EMS System

CARS Program Personnel Password/Change Request Form

To ADD EMT-Bs

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

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

Administrative Access Addition/Change

CARS Program
Personnel Password/Change Request Form