Hudson Hybrid EMR 2020

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This form needs to be completely filled out. Any questions about enrollment can be directed to McLean County Area EMS System at 309-827-4348.

Your enrollment will not be considered complete until payment is received in full. Checks can be made out to: McLean County Area EMS System

Email *

Email Address *

First Name *

Last Name *

Date of Birth *

YYYY

Drivers License or State ID Number *

State on drivers license or ID *

Address *

City *

State *

Zip Code *

Are you currently on a department? *

Yes

If on a department, which department?

Have you ever been convicted of a felony? *

Yes

Have you ever been licensed as a provider previously? *

Yes

Have you ever have had your medical license suspended or revoked?

Yes

Not Applicable

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