Nebraska Department of Health and Human Services
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EMS Educational Training Materials Loan Service
Request Form

Sponsored by Nebraska Emergency Medical Services Program

This form is ONLY to be used by Nebraska EMS services, instructors, and training agencies. Please fill out a form for each item you are requesting and submit. The Nebraska EMS Program loan policy/FAQs can be found at http://www.dhhs.ne.gov/ems/emsvideoFAQ.htm. If you have any questions, please call (402) 224-3298 or (877) 669-0763 or e-mail garry.steel@dhhs.ne.gov.

Items in BOLD are required.

Borrower is an:
Requested by:
Mailing address:
City:
State:
Zip code:
Phone number:
Cell phone number:
E-mail address:
Date needed by:
(Please allow for mailing time)
<September 2008>
SunMonTueWedThuFriSat
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
DVD/Video tape title:  #: 
Teaching guide (if available)?
Purpose for using the video or DVD: