Individual Registration

Peterborough AEMT Class

Username*

Password*

Retype password*

Last Name *

First Name *

Address *

City *

Zip *

State *

Phone *

Email *

Personal email preferred as some business email systems may filter communication related to your enrollment.

Date of Birth

This is not required now but will be required later for the State final roster.

Last 4 Digits of SS#

This is not required now but will be required later for the State final roster.

Coupon

Amount

Discount Amount

Gross amount

Deposit Amount

Payment Type

Payment Method *

Credit Card Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*