Committee on Accreditation
of Educational Programs for the Emergency Medical Services Profession

All new programs must complete and submit this form before payments can be accepted.

PROGRAM CONTACT INFORMATION

Sponsor Name:
Street Address 1:
Street Address 2:
City: / State: / ZIP:
Contact Person for Billing:
Email:
Telephone:

TYPE OF SELF STUDY REPORT (SSR) / ESTIMATED SUBMISSION DATE

Type of SSR Submission: Click here to Select... Initial-Accred Self Study Report (ISSR) Letter of Review Self Study Report (LSSR)
Anticipated Submission Date: Month: Click to Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year: Click to Select... 2012 201320142015201620172018

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FEES DUE WITH SUBMISSION OF SELF STUDY REPORT

Self-Study Report Evaluation Fee / Technology
Fee / First Annual
Fee / Site Visit
Fee
$500
If submitting an LSSR, a second Self Study Report Fee will be assessed at the time of submission of ISSR / $250
One-Time only fee / Prorated
see table below * / Only submitted with the ISSR (not the LSSR)
$2700

*ANNUAL FEE PRORATION TABLE

Jan / Feb / Mar / Apr / May / Jun / Jul / Aug / Sep / Oct / Nov / Dec
$ 500 / $ 400 / $ 300 / $ 200 / $ 100 / $1200 / $1100 / $1000 / $ 900 / $ 800 / $ 700 / $ 600


* The first annual fee is prorated at $100/month for the # of months starting with the month after submission of the ISSR/LSSR through June 30. Subsequently, programs in the process of becoming accredited or holding an accreditation status are invoiced for the full annual fee of $1200 in May each year, payable no later than July 31.
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FEE WORKSHEET

First Annual Fee (from Table above)
Technology Fee / $250
Self Study Report Evaluation Fee / $500
Site Visit Fee w/ISSR ONLY: Add $2700

TOTAL TO BE INVOICED $

Please download, complete, and return this form to Ruth Crump at .

Upon receipt of this request an invoice will be generated and EMAILED to the contact person listed above. All inquiries regarding invoices should be directed to Ms. Crump. Thank you. Rev. 12/152012