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Firefighter, Fire Instructor, Fire Safety Inspector, Non-Emergency, Emergency, or Air Medical Service Organization) SERVICE OR INSTITUTION NAME SERVICE OR INSTITUTION ID NUMBER STREET ADDRESS OF SERVICE OR INSTITUTION CITY STATE ZIP CODE INDIVIDUAL LAST NAME TELEPHONE NO. EXT. FIRST NAME STREET ADDRESS APT STATE COUNTY EMS/FIRE CERTIFICATE NUMBER (If known) MI CITY TELEPHONE NO. ZIP CODE EXT. LEVEL OF EMS/FIRE CERTIFICATION (If known) EMS OR FIRE AGENCY - AFFILIATION EMS OR F.

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