CONFIDENTIAL NOTICE OF INTEREST * Note: Please Fill Out Entire Form PART-TIME FULL-TIME Name: Address: City:   State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY    Zip Code: Certification/License:     EMT     IEMT     CEP     RN     DISPATCHER Arizona Certification/License #:         Expiration Date:  Other Certifications:      CPR      ACLS      PALS/PEPP      Other    Languages Spoken:     English     Spanish     Other    Languages Written:     English     Spanish     Other    Contact At: Current Employer: E-Mail Address: *If Part-Time please give your availability: Other information you want to supply:

	© 2002 American LifeStar