Free 53533.FH11 - Indiana

RESERVATION FOR PRACTICAL SKILLS EXAMINATION
State Form 53533 (3-08) DEPARTMENT OF HOMELAND SECURITY

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DEPARTMENT OF HOMELAND SECURITY - TRAINING 302 West Washington Street, Room E239 Indianapolis, Indiana 46204 Telephone: (317) 232-3980

INSTRUCTIONS:

1. 2. 3. 4.

REMINDER:

Please complete this Reservation and send it to DHS at the above address. You may fax this reservation at your own risk. The DHS training staff must receive this Reservation thirty (30) days or more prior to the date of the requested examination. A minimum of nine (9) rooms are required for EMT-B. A minimum of six (6) rooms are required for EMT-BA. There is a minimum of ten (10) students per practical examination site. If your course has less than ten (10) students, you will need to consolidate with another course. There is no need for you to find your Practical Skills Representative. DHS will contact your Practical Skills Representative and ensure that he/she has all of the necessary examination documentation materials, which will allow you more time to be sure your equipment, rooms, and evaluators are appropriate. The Department of Homeland Security will send additional Representatives as needed for larger examinations.
Check one

Type of practical skills examination

EMT-B

EMT-BA

We will NOT be able to accept additional students (we have 15+ students). We WILL ACCEPT additional students to our examination roster.

Name of training institution Name of training institution official Name of primary instructor Date requested (month, day, year) E-mail address Orientation start time Telephone number

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Telephone number Course number

Address / location of practical site (name of site, street, city, state, and ZIP code)

NAME OF STUDENT OR EXAMINEE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Page 1 of 2

INITIAL or RETEST

CRS NUMBER

NAME OF STUDENT OR EXAMINEE 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. Page 2 of 2

INITIAL or RETEST

CRS NUMBER