GOLD STAR PROVIDER APPLICATION

Name: ______________________________________________________________________

Business Name: ____________________________________________________________

Address: ____________________________________________________________________

______________________________________________________________________________

Telephone: _________________________________________________________________

Fax: ________________________________________________________________________

Email: ______________________________________________________________________

Member Number: ___________________________________________________________

Number of hours of documented training (excluding CPR and First Aid):

______________________________________________________________________________

Date of CPR & First Aid Training:

______________________________________________________________________________

PROVIDER CHECKLIST

The following items must be enclosed in order to process your application:

________ Current state registration certificate

________ Proof of CPR & First Aid Training

________ Copies of training certificates documenting ten (10) training hours within the past

year (excluding CPR & First Aid) in the past year.

Send completed application and documentation to:

NJFCCPA

 88 Vincent Drive

Burlington Township, NJ 08016