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Application for Emergency Medical Services Certification

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Application for Emergency Medical Services Certification Page 2
DOH-65 (1/2009) page 2 of 2
1. Fill out this form legibly and accurately. Failure to do so can cause delay in your being allowed to test or
inaccurate information on your certificate.
2. COURSE NUMBER: Fill in the course number. It is provided to the Instructor/Coordinator on the course
approval slip.
3. Check ORIGINAL CERTIFICATION Box if:
A. This is the first time you have enrolled in an Emergency Medical Services certification course or,
B. You are applying for an advanced EMT certification in a category in which you are not currently certified.
4. Check RECERTIFICATION COURSE box if you are applying for recertification, basic or advanced.
5. EMS IDENTIFICATION NUMBER: Enter the six (6) numbers of your EMS identification number. If your number
is less than six digits, add zeros in front to complete the number of six digits (Example: EMS No. 94 would be
000094). Only enter your New York State EMS number.
6. NAME: Enter your last name. If you use a notation after your name (such as Jr.) enter it after your last name.
In the next set of boxes, enter your first name in full, leave a space, and enter your middle initial. If you do
not have room to enter your name in full, please abbreviate.
7. If you EMS certificate shows an incorrect name or you have changed your name since it was issued, check the
box and write in the name that is on your current certificate.
8. ADDRESS: Write your mailing address. The first line is for your number and street, or post office box. Leave a
space between words for box numbers. The second line is the city, state and the third line is for zip codeand
county where you will be receiving your mail.
9. COUNTY: Enter the county in which you live. NOTE: Manhattan is New York (NEWY) - Staten Island is
Richmond (RICH) - Brooklyn is Kings (KING) - St. Lawrence is STLA - Out of State is OUTS
10. DATE OF BIRTH: Enter your date of birth putting two digits each in the month, day and year boxes. Always
use a "0" to complete 2 digits (i.e. January is "01")
11. SOCIAL SECURITY: Please fill in the last 4 digits of your social security number. This will be kept confidential
by the New York State Department of Health and the Bureau of Emergency Medical Services.
12. SEX: M for male, F for female.
13. If you are part of the teaching faculty for this course, check Yes.
14. AGENCY CODE: Fill in the Department of Health numerical code assigned to the agency with which you
provide prehospital care.
15. PRACTICAL SKILLS EXAM DATE: Fill in the date(s) of your Practical Skills Exam. This date will be provided by
the Instructor/Coordinator.
16. EXAMINATION DATE: Fill in the date that you will be taking the NYS certifying exam. This date will be
provided by the Instructor/Coordinator.
17. Read the statement and sign the application (if able) as you normally sign your name, and write in today's
date. You are responsible for the statement's truth and accuracy.
Application for Emergency Medical Services Certification
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