Please complete the form below to register for the Roxana 24 HR EMT Refresher Class to be held on 1/17/2015, 1/18/2015, 1/24/2015:

      CLASS TO BE HELD AT ROXANA FIRE COMPANY , STATION 90,  39453 Zion Church Road, Frankford, DE 19945

1/17   Saturday  0800 - 1700 hrs

1/18    Sunday   0800 -- 1700 hrs

1/24    Saturday  0800 -- 1700 hrs

Cost for class is $100 and payment is due at time of registration. Acceptable forms of payment are cash, money order, business check, Visa, MasterCard or Discover.  Please call (302) 223-5315 for payment arrangements.

If you select Bill Fire Company/Employer and your Fire Company/Employer denies authorization/payment you will be financially responsible for payment. 

FIRST NAME	*
LAST NAME	*
PAYMENT METHOD	*	BILL FIRE COMPANY BILL EMPLOYER SELF-PAY
AFFILIATION/EMPLOYER	*
APPROVING INDIVIDUAL	*
EMAIL	*
PHONE NUMBER	*
MAILING ADDRESS	*
CITY	*
STATE
ZIP CODE
SELECT COURSE		Roxana January 2015 24 HR EMT Refresher
Security Code	*
COMMENTS/NOTES