New Course Management System Lumens

Please fill out the information requested NO LATER than August 26, 2013.

*1

Last Name

*2

First Name

3

Middle Name/Initial

4

Maiden Name (if applicable)

*5

Home Address

Address / P.O. Box / Apt. #

CityStateZIP

6

Phone number

7

Please select your gender

Female

Male

n/a

8

Social Security Number

You must answer either question number 8 SS Number or question number 9 St. Petersburg College Student ID number in order to be registered for CME.

9

St. Petersburg College Student ID Number

You must answer either question number 8 SS number or question number 9 St. Petersburg College Student ID number in order to be registered for CME.

*10

Birthdate

*11

Employer Name (Agency

CTRL-Click to select (or de-select) more than one option in the dropdown box above

*12

Employer Address(Agency)

Address / P.O. Box / Apt. #

CityStateZIP

*13

Employer phone number

Extension

14

Job Title

*15

EMS County ID Number

16

EMT, Paramedic, RN License Number

*17

E-mail Address-one you look at frequently

If you have comments about this form or questions regarding how to complete this form, please contact Melissa Hudak at Hudak.Melissa@spcollege.edu or call (727)341-3741.

The Board of Trustees of St. Petersburg College affirms its equal opportunity policy in accordance with the provisions of the Florida Educational Equity Act and all other relevant state and federal laws, rules and regulations. The college will not discriminate on the basis of race, color, ethnicity, religion, sex, age, national origin, marital status, pregnancy, sexual orientation, gender identity, genetic information, or against any qualified individual with disabilities in its employment practices or in the admission and treatment of students. Recognizing that sexual harassment constitutes discrimination on the basis of sex and violates this Rule, the college will not tolerate such conduct. Should you experience such behavior, please contact the Title IX Coordinator and EAEO Officer at 727-341-3055; by mail at P.O. Box 13489, St. Petersburg, FL 33733-3489; or by email at eaeo_director@spcollege.edu or spctitleix@spcollege.edu.