Actuel Page 1 Page 2 Aperçu Personal information on this form is collected by the Emergency Medical Services Board of Prince Edward Island under the authority of the Prince Edward Island's Emergency Medical Technicians Act and Emergency Medical Technicians Regulations. This information will be used to determine eligibility for an emergency medical technician (EMT) licence and to maintain a register of licensed EMTs in the province. The collection, use, or disclosure of this information must be in accordance with the Freedom of Information and Protection of Privacy Act, R.S.P.E.I. 1998, c.F-15.01. If you have any questions about this collection of personal information, contact the Director, Emergency Health Services; 16 Fitzroy Street, 3rd Floor Sullivan Building, PO Box 2000, Charlottetown, PE, C1A 7N8 or by phone at 902-368-6719. Identification Prénom Initiale Nom Adresse 1 Adresse 2 Ville, municipalité, communauté Province Code postal Exemple : C1B 0X1 ou 12345 Pays Numéro de téléphone Exemple : 902-555-5555 Adresse courriel Cell Phone Number For example 902-555-5555 Are you proficient in English? - Sélectionner -YesNo What is your mother tongue? - Sélectionner -EnglishFrenchOther Other What is your preferred language to deliver service? - Sélectionner -EnglishFrenchOther Other