ALS Eligibility to Test Application

Exam Information
Please refer to the ALS exams section of our website to see a current list of ALS exams.
Exam Date Requested*
Date Format: MM slash DD slash YYYY
Location *
Level*
Exam Attempt*
Previous Test Date
Date Format: MM slash DD slash YYYY
Previous Test Location
Candidate Information
Legal Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Cellphone*
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Current Certifications
Current NREMT Certification:*
- Yes
- No
NREMT #:
Expiration Date
Date Format: MM slash DD slash YYYY
If you do not have National Registry certification, do you hold a current State certification:
- Yes
- No
State Certification held in:
Level of Certification:
Certification #:
Expiration Date:
Date Format: MM slash DD slash YYYY
A copy of you current out-of-state certification is required, please upload a copy:
Course Information
Course #:
Course Instructor:
Course Completion Date*
Date Format: MM slash DD slash YYYY
Course Location:
For non-New Hampshire training programs please include a copy of a letter or certifcate of completion from the State authorizing the EMS training program. Please upload a copy here:
AFFIRMATION - I understand and agree to have the Division send my application information directly to the appropriate testing agency. This information sent to the testing agency shall only be used for registration purposes.*
- I Understand
- I DO NOT Understand

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We are committed to training, educating, and certifying emergency and community responders to protect the citizens and visitors of New Hampshire.

98 Smokey Bear Blvd
Concord, New Hampshire 03301

fstems@dos.nh.gov

©2020 New Hampshire Department of Safety
Division of Fire Standards and Training & Emergency Medical Services. All Rights Reserved.

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