New Jersey Department of Health

Office of Emergency Medical Services	STAFF ROSTER
Please Print or Type

Instructions:

Print your services full trade name (as it appears on your vehicle and today’s date in the box below.

Print the full name of every person who will staff any of your vehicles.

Print the required information for each person, including social security number and course/expiration dates.

Make additional copies of this blank form as needed

Trade Name of Service (exactly as it appears on your vehicles):

Staff Person

(Last Name, First Name)	Ambulance Staff	MAV Staff	Drivers License Expiration Date
EMT ID Number and Exp. Date	CPR Expiration	MAVT

Cert. (Exp.)	CPR Expiration
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STAFF ROSTER, Continued

EMS-38

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

ems-38, Staff Roster

ems-38, staff roster, emergency medical services, EMS, mav, ambulance, emt

EWHITE

2006-04-25

NJDOH