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Application for Emergency Medical Services Certification


Application for Emergency Medical Services Certification
Application for Emergency Medical Services Certification
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services
Please print le
g
ibly in capital letters or type. Put letter or number in each box.
Application for Emergency Medical
Services Certification
Course Number (Please retain this number for future reference)
Check if this application is for: Original Certification Recertification (If you are recertifying you must
include your NYS EMS I.D. Number)
EMS Identification Number (If you have one)
Only write your NYS EMS number in this space
Last Name
First Name and M.I.
Check this box if your name as stated above has changed or is spelled differently than on your current EMS card.
Enter on the line below, your name as it appears on your current EMS
card.
(Please Print Clearly or Type)
Address
Number and Street
(Skip one space between number and street)
City State
Zip Code County Date of Birth
Month Day Year
Social Security Sex On Teaching Faculty
(Enter M or F)
YES NO
If you belong to an EMS agency, please indicate the agency code in the box(es) below.
Primary EMS Agency Secondary EMS Agency
Day Telephone Practical Skills Exam Date NYS Written Exam Date
X X X X X
Month Day Year Month Day Year
Personal Affirmation Read Carefully Before Signing
I affirm that in accordance with the requirements of 10 NYCRR Part 800, I have NOT been convicted of any misdemeanors or felonies. I
understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification. The
Department of Health will determine if the conviction is applicable under the provisions of Part 800.
Do not sign this if you have any convictions
I hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as
applicant. I further understand that offering or providing false information on this document may constitute a crime under the penal
law and may subject any certification to revocation or other Department action.
(Applicant Signature) (Date)
DOH-65 (1/2009) page 1 of 2
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Application for Emergency Medical Services Certification
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