Virginia EMS Councils

Vendor proposal for EMS continuing education courses and/or EMS auxiliary courses

Category 1 Combined ALS / BLS CE Program (Deadline for submission – July 31, 2017)

EMS Auxiliary Program * (Deadline for submission – ongoing through May 30, 2018)

Instructor Information:

Last Name

First Name

Middle Int.

Business Name, if applicable:

Street Address:

City/State

Zip

Telephone (Home/Cell):

Telephone (Work):

Email Address:

Please describe your (and/or your designated instructors’) past successes in providing EMS CE courses and/or auxiliary courses, as applicable:

Indicate, by name, OEMS certification number (if applicable), and with a brief background of qualifications, other instructor(s) to be utilized to teach any part of this course. This information may be updated later, but must be provided to the council at least 30 days in advance of instructor utilization:

VA Certification Level:

Certification #:

Expiration Date:

VA Instructor Certification Level:

ALS Coordinator

Education Coordinator

Certification #:

Expiration Date:

Program Information: (When and where will the program be conducted?)

Address**: Street / City / Zip

** Will be in VARIOUS Locations – Please List

Yes

No

Expected Dates of Program(s):

If this is a proposal for an auxiliary course, check the appropriate course name:

Projected Number of Courses (Name & Number):

Has a Course Approval Form already been submitted to OEMS for this course?

Yes

No

If YES, then please submit a copy to the Blueridge EMS Council via email at blueridge@vaems.org or fax to (434) 947-3987.

By submitting this proposal are you representing an OEMS-defined “Designated Emergency Response Agency (DERA)”?

Yes

No

If yes, please identify:

Optional comments and other information:

By submitting this proposal I agree to the terms and conditions of the Request for Proposal issued by the Blueridge EMS Council to conduct Category 1 EMS Continuing Education and/or EMS Auxiliary Courses.

I agree