Course Request Form

***NOTE:  The Regional Director must receive this application no later that thirty (30) days prior to the beginning of the course.  Open courses will be listed in the Tennessee ITLS Web Site.

Please complete and submit the form below:

Application Date: (mm/dd/yy)
Projected Course Dates:  Start:   End:
Type of Course:
Course Location:
Region:
County:
Sponsoring Agency:
Course Coordinator:
Contact Number: (xxx-xxx-xxxx)
Email:
Course Medical Director:
Course Affiliate Faculty:
Open or Closed Course?
Comments:


submit only once

 

 

 

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P.O. Box 621
Seymour, TN 37865
866-ITLSTN1
(485-7861)
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