State of California
Child Care Training Course Completion Sticker Request EMS 900 (Rev. 03/01)
Instructions: 1. Complete program information. Be sure to print legibly or type. This information will be used to identify you and a shipping address. If you do not have a program approved by EMSA and are teaching another program as an approved instructor, Program Name would be the name of your business (DBA) and Affiliation would be the name of the program you are teaching. 2. Identify the number and type of course completion stickers you would like to purchase. The cost is $3.00 per sticker. Do not include sales tax. 3. Make out a check or money order to: Training Program Approvals Fund or TPA Fund. DO NOT SEND CASH. 4. Mail completed form and check to: EMS Authority ATTN: Child Care Stickers 10901 Gold Center Drive 4th Floor Rancho Cordova, CA 95670-6073 PROGRAM OR INSTRUCTOR COMPLETE THIS PART: Program Name or DBA:
Affiliation:
Your Name:
Phone:
Ship to Address (Street or P.O. Box):
Date: City, State, Zip Code:
E-Mail Address (optional): Number of First Aid Stickers:
Number of CPR Stickers:
Total Fees Enclosed:
Number of Preventive Health Stickers:
Check or Money Order Number:
$0.00 TO BE COMPLETED BY EMSA: Assigned FA:
Assigned CPR:
Assigned Prev Health:
Delivery Tracking #:
Amount Due:
Filled By: