nemsma leadership education provider office use only ......nemsma leadership education provider...
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NEMSMA Leadership Education Provider OFFICE USE ONLY
Application for Registration Form Received Payment Received $ ☐ Fee Waiver ☐ Conference (First Year)
☐ Strategic Partner/Sponsor
NEMSMA FORM: CA‐1 Payment: ☐CC ☐ PO ☐Ck# Certificate Sent
Leadership Education Provider Information Organization Name Trade Name (if different) Primary Physical Address City State Zip Administrative Phone Fax E‐Mail Website Federal Employer Identification Number (EIN) Mailing Address Check if same as Physical Address Address City State Zip The organization has been under continuous operation under ownership described herein since what date? Has the organization and/or any of its sites operated or received licensure within the last ten (10) years under a different name and/or address? YES NO If yes, provide the previously used name and/or address: Application Type (Please select one)
Initial Organizations never previously recognized by NEMSMA as a Registered Leadership Education Provider.
Renewal Organizations currently recognized by NEMSMA seeking renewal of Registration. RLEP ID #
Reinstatement Organizations previously recognized by NEMSMA whose Registration has lapsed. RLEP ID #
Contact Information Primary Contact Title Address Email City Phone State Zip Mobile Secondary Contact Title Address Email City Phone State Zip Mobile Legal Nature of the Organization
1. Indicate the legal tax status of your organization by checking the appropriate box: For‐Profit Entity Non‐Profit Entity (Written Notice must be provided from the IRS as attachment) 2. Identify the type of legal entity of the organization by checking all that apply:
Corporation Wholly‐Owned Subsidiary Partnership Sole Proprietorship
Personal Service Corporation (PC) Limited Liability Company (LLC) General Partnership
Limited Partnership (LP) Limited Liability Partnership (LLP) Professional/Trade Association
If Other, please identify:
Intended Educational Delivery Model (Please select all that apply) Fixed Location National Conference(s) Distributive Education (Periodical(s)) Remote Locations Worldwide Conference(s) Other (Please Describe): State Conference(s) Distributive Education (Online) Regional Conference(s) Distributive Education (Video)
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Faculty Information Does the organization use Authorized Trainers and/or Training Center(s) to deliver its educational content? YES NO If YES, does the organization have a process in place to properly vet, educate, authorize and monitor instructors to teach accredited programs? YES NO If NO to either of the above, describe how the organization ensures/plans to ensure that accredited educational content will be delivered consistent with NEMSMA Accreditation standards: Organizational Background If the answer to any of these questions is “YES,” Please attach documentation to explain the findings:
YES NO Is the organization and/or any of its sites currently under an appeal, show cause, probation, warning, or any form of adverse status with any state or federal agency?
YES NO Has your organization previously had accreditation or licensure revoked, suspended, or placed on probation? YES NO Has your organization previously been found guilty in any civil judgement?
YES NO Is your organization or anyone employed by or affiliated with it on the OIG List of Excluded Individuals and Entities (LEIE)?
Fees (Included) Application for Initial Registration $285.00
Please Check only one box for current period of application. NEMSMA accepts credit cards, checks, and purchase orders. Please use the Payment Information form below.
Conference Waiver (First Year Only) $0.00 Application for Renewal of Registration $95.00 Application for Reinstatement of Registration $285.00
NEMSMA Strategic Partner/ Sponsor $0.00
Strategic Partner Platinum Gold Silver Management Development/ Education Partner
Signature & Attestation The undersigned, authorized representative of this organization hereby attests to the following statements: I have read our application for NEMSMA Leadership Education Provider Registration, and affirm that all statements made herein or in any document attached hereto are accurate, complete, true and correct in every aspect. During the application process and upon and following accreditation, the organization will abide by and support the following:
‐ The NEMSMA EMS Officer Competencies License; ‐ The NEMSMA Registered Leadership Education Provider Eligibility Requirements; ‐ Application Submission Portal Terms & Conditions of Use; ‐ The NEMSMA standards for accreditation; and ‐ The NEMSMA policies, procedures and practices
Following registration, the organization agrees it will notify NEMSMA in a timely manner of email and physical address changes, changes in organizational status, adverse actions by any state or federal agency or accreditation or licensure body, and that it will frequently check the NEMSMA website at https://nemsma.org to obtain any modifications to the items listed in the paragraph above. ______________________________________________________________________ NAME OF ORGANIZATION By: _______________________________________________________________ Date: ______________________ signature Name: _______________________________________________________________ printed Title: _______________________________________________________________
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Payment Information
NEMSMA accepts credit cards, checks, and purchase orders for payment of required fees.
Form of Payment: ☐ Check ☐ Credit Card ☐ Purchase Order
********************************************************************************************* To Pay by Check or Purchase Order:
Make all checks payable to “NEMSMA”. Please note “RLEP Registration” somewhere on your check. Mail Checks to:
National EMS Management Association, Inc. P.O. Box 472
Platte City, MO 64079
NOTE: Please DO NOT send completed applications to this address. If you are paying by check, email the completed application along with this form to [email protected], and mail a copy of this form along with your check to the address above. NEMSMA will NOT accept applications submitted by U.S. Mail.
If you are paying by Purchase Order, attach a copy of the Purchase Order to this application and email it to [email protected]. Please note “RLEP Registration” somewhere on your Purchase Order.
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To Pay by Credit Card:
Please complete the form below and email it along with the attached application to [email protected] Please charge my: ☐ VISA ☐ MasterCard ☐ American Express Name of Organization: Card Number: Card Holder’s Name: Billing Zip Code: Expiration Date: Amount to Charge: ☐ Initial RLEP Registration ($285) ☐ Annual Renewal of RLEP Registration ($95) ☐ Reinstatement of RLEP Registration ($285) I authorize NEMSMA to charge the above amount. Authorized Signature: Date: Contact Phone Number:
********************************************************************************************** Applications will NOT be processed until payment is received! Please plan accordingly.
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Instructions All sections of the application must be filled out in their entirety. All information is required unless otherwise noted. Incomplete applications will not be accepted. Registered Leadership Education Provider Information
Organization Name –Enter the legal name of the organization applying for registration
Trade Name – Enter the trade name of the organization if different from the legal name. The trade name is the “doing business as” (DBA) name. If the organization does not use a trade name, enter “N/A.”
Primary Physical Address – Enter the physical (street) address of the organization. Do not enter a P.O. Box number here.
Administrative Phone – Enter the main phone number for the organization.
Email – Enter the main (or “general”) email address for the organization. If the organization does not have main email address, enter “N/A.”
Website – Enter the organization’s website address. If the organization has more than one website, enter all applicable website addresses. If the organization does not have a website, enter “N/A.”
Federal Employer Identification Number (EIN) – Enter the organization’s Employer Identification Number (EIN). An EIN is a nine‐digit number (for example, 12‐3456789) assigned to sole proprietors, corporations, partnerships, estates, trusts, and other entities for tax filing and reporting purposes. If you are a sole proprietor, do NOT enter your Social Security Number. If you do not have an EIN, one can be obtained from the Internal Revenue Service at www.irs.gov.
Mailing Address – Enter the mailing address for the organization’s correspondence. If the mailing address is the same as the organization’s Physical Address, check the box.
Continuous Operation – Enter the date (MM/DD/YYYY) since which the organization has been in continuous operation from.
Previously Used Name and/or Address – If the organization was previously operated under a different name and/or from a different address within the past ten (10) years, enter the applicable information.
Application Type (Select only one)
Initial – For first‐time registration applicants only.
Renewal –For organizations which are currently Registered Leadership Education Providers and are renewing their registration prior to or not more than 90 days following the last day of the month of the initial registration anniversary date (e.g., if initial registration anniversary date is January 10, renewal must be received no later than
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April 30). Registered Leadership Education Providers with registrations expired beyond 90 days must apply for Reinstatement (see below). Note: Registration must be renewed annually along with the payment of all other applicable fees in order to maintain Registered Leadership Education Provider registration in good standing.
Reinstatement – For organizations which failed to renew their Registered Leadership Education Provider registration within 90 days following the last day of the month of their initial registration anniversary date. Note: In the event of a lapse of registration, any accredited course offerings will no longer be recognized as Accredited and the organization must re‐register as a Registered Leadership Education Provider and resubmit their program offering(s) for re‐accreditation, including the payment of all applicable accreditation fees.
RLEP ID # ‐ If the application is for Renewal or Reinstatement, enter the previously‐assigned NEMSMA Registered Leadership Education Provider (RLEP) Identification Number. The RLEP ID # can be found on previous RLEP registration/renewal certificates. The RLEP ID # is different from program or conference accreditation registration numbers. DO NOT enter program or conference accreditation identification numbers. If you do not know your RLEP ID # or are having difficulty locating it, contact NEMSMA’s Committee on Accreditation at [email protected].
Contact Information
Primary Contact – Enter the name and all contact information details requested for the organization’s primary point of contact for NEMSMA‐related Registered Leadership Education Provider registration and accreditation matters.
Secondary Contact – Enter the name and all contact information details requested for the organization’s secondary point of contact for NEMSMA‐related Registered Leadership Education Provider registration and accreditation matters. If there is no secondary point of contact, enter “N/A.”
Legal Nature of the Organization
Tax Status of Organization – Identify the type of legal tax status of the organization.
For‐Profit – All organization types other than non‐profit.
Non‐Profit ‐ An organization granted tax‐exempt status by the Internal Revenue Service (IRS). Written notice of non‐profit status granted by the IRS must be provided as an attachment.
Type of Legal Entity – Check the box which best describes the type of legal entity of the organization.
Corporation – Check this box for any type of corporation other than a personal service corporation.
Wholly‐Owned Subsidiary – A wholly‐owned subsidiary is a company whose stock is entirely owned by another company. The owner of a wholly‐owned subsidiary is known as the parent company or holding company. Partnership – A business organization of two or more people who pool some or all of their money, abilities, and skill in a business and divide profit and loss in predetermined proportions.
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Sole Proprietor – A business or financial venture that is carried on by a single person and is not a corporation or limited liability company. Personal Service Corporation (PC) – Check this box if the organization is a personal service corporation. Personal services include the performance of services in such fields as accounting, actuarial science, architecture, consulting, engineering, health (including veterinary services), law, and the performing arts.
Limited Liability Company (LLC) – An LLC is a business organized under the laws of a state or foreign country as a limited liability company.
General Partnership – A general partnership is an arrangement by which partners conducting a business jointly have unlimited liability, which means their personal assets are liable to the partnership's obligations. Limited Partnership (LP) – A limited partnership (LP) exists when two or more partners unite to jointly conduct a business in which one or more of the partners is liable only to the extent of the amount of money that partner has invested.
Limited Liability Partnership (LLP) – A limited liability partnership (LLP) is a partnership in which some or all partners (depending on the jurisdiction) have limited liabilities.
Professional/Trade Association – A professional or trade association (also known as an industry trade group, business association, sector association or industry body) is an organization founded and funded by businesses that operate in a specific industry.
Other – If the type of legal entity of the organization is not listed, please identify.
Intended Educational Delivery Model
Identify all intended educational delivery models the organization engages in, provides or intends to provide at the time of application. Select all that apply. You must select a minimum of one.
Faculty Information
Authorized training centers are allowed by NEMSMA, but organizations must have a comprehensive process in place to properly vet, educate, authorize and monitor instructors teaching accredited Programs. Documentation of the vetting process for faculty conducting Programs through or at authorized training centers must be provided to NEMSMA upon request.
Organizational Background
If the answer to any of these questions is “YES,” please provide full details and supporting documentation (e.g. certified court copy with court seal affixed, complaint, answer, judgment, settlement, or disposition) to assist with NEMSMA’s review.
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Fees
NEMSMA accepts credit cards, checks, and purchase orders for payment of required fees. Checks should be made payable to: NEMSMA ALL FEES ARE NON‐REFUNDABLE Application for Initial Registration – This one‐time fee allows an organization to become designated as a NEMSMA “Registered Leadership Education Provider” or “RLEP.” Organizations must be registered with NEMSMA in order to apply for NEMSMA Accreditation of conference sessions, courses, workshops, or programs. Note: Registration does not mean that educational offerings are automatically accredited.
Conference Waiver – For Conferences providers / hosts / organizers ONLY – NEMSMA will waive the Initial Registration for your first year on a one‐time only basis! (The organization will be charged the full amount of the Initial Registration Fee (e.g. $285) in the first year of renewal, i.e., Year 2) Note: Course, workshop and program leadership education providers are not eligible for this waiver. If you are applying to become a RLEP for the first time and are hosting a conference, do not check the “Application for Initial Registration” box, but instead check the “Conference Waiver (First Year Only)” box.
Application for Renewal of Registration – For organizations which are currently Registered Leadership Education Providers and are renewing their registration prior to or not more than 90 days following the last day of the month of their initial registration anniversary date (e.g., if the initial registration anniversary date is January 10, renewal must be received no later than April 30). Registered Leadership Education Providers with registrations expired beyond 90 days must apply for Reinstatement (see below). Note: Registration must be renewed annually along with the payment of all applicable fees in order to maintain Registered Leadership Education Provider (RLEP) registration in good standing.
Application for Reinstatement of Registration – For organizations which failed to renew their Registered Leadership Education Provider registration within 90 days following the last day of the month of their initial registration anniversary date. Note: In the event of a lapse of registration, any accredited course offerings will no longer be recognized as Accredited and the organization must re‐register as a Registered Leadership Education Provider and resubmit their course offering(s) for re‐accreditation, including the payment of all applicable accreditation fees.
NEMSMA Strategic Partner / Sponsor – Identify level of partnership/sponsorship. No Registration, Renewal, or Reinstatement fees are required for NEMSMA Partners and Sponsors.
Signature & Attestation
The application must be signed by an authorized representative of the organization.
Completed Form and Payment
The Completed form and all attachments must be emailed to: [email protected]
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If paying by check, payment must be submitted separately to:
National EMS Management Association, Inc. P.O. Box 472
Platte City, MO 64079
NOTE: Please DO NOT send completed applications to this address.
Questions concerning the completion of this form should be directed to: [email protected]
For more information on NEMSMA Accreditation, Visit our website at www.nemsma.org
Or email us at [email protected]