This form is also available in PDF format.

NJ EMT-Bs may receive 2.0 elective CEUs per calendar year for healthcare professional level CPR renewal through the American Heart Association, American Red Cross or National Safety Council.  You may only use a CPR card issued during the period of EMT-B certification when the CEU credit is needed.  Credit is effective on the issue date.  To receive CEU credit:

1.  Copy your entire CPR card so that the training site/instructor, expiration date, your name and signature are visible.  Attach the copy to this form.

2. Complete the following information:

     Name (as appears on EMT card):______________________________

     Current address:_______________________________________________
     ___________________________________________________________
     ___________________________________________________________

     SSN (EMT ID#):_________________________     DOB:_____/_____/19_____

4.  Read and sign the statement below:

Please credit me with 2.0 elective CEUs for the CPR renewal attached.

5.  Mail this form and attached copy of CPR card to:

NJ Dept. of Health & Senior Services
Office of Emergency Medical Services
P.O. Box 360
Trenton, NJ  08625-0360

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