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EMERGENCY MEDICAL TECHNICIAN - (EMT) APPLICATION

APPLICATION TYPE CHECK ONE: [ ] INITIAL CERTIFICATION [ ] RECERTIFICATION

LAST NAME____________________________________ FIRST NAME ________________________ MI________

ADDRESS __________________________________________________________________________________________________

CITY ________________________________________________________________STATE _________ ZIP ____________

CELL PHONE # ( ) _____ - _________ SOCIAL SECURITY # ___________-___________-___________

BIRTHDATE _______/________/_______ DRIVERS LICENSE # _____________________________ STATE ____________

California EMT #: E_________________ ISSUE DATE _____________________ EXPIRATION DATE _____________________

EMS Employer Name and Address_______________________________________________________________________

EMT Training and Continuing Education Units

[ ] EMT Basic [ ] EMT Refresher [ ] CEUs* (please list below & attach CEU certificates)

If EMT Basic or EMT Refresher Course, indicate name of Course Provider ____________________________________________

Date of Course Completion ________/_________/________

* List Continuing Education Units - must total 24 hours* (Recertification Applicants only)

| | | | |# of Course |SF EMS Agency |

|Course Date |Course Title/Topic |Approved CE Provider Name |CE Provider Number |Hours |Use Only |

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ANSWER THE FOLLOWING QUESTIONS BEFORE SIGNING THIS APPLICATION:

[ ] yes [ ] no Have you ever had a certification, accreditation, or professional license denied, suspended, revoked, placed on probation, or are you under investigation at this time?

[ ] yes [ ] no Are there criminal charges pending against you?

[ ] yes [ ] no Have you ever been convicted of any felony or misdemeanor offense in California or in any other

State or place, including entering a plea of nolo contendere or no contest, and including any

conviction which has been expunged (set aside) under Penal Code Section 1203.4?

If you answered Yes to any of the above questions, attach a written explanation describing the crime, date, location, court, conviction, corrective action, and/or remediation. Attach DMV, court, and police records.

I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief. I understand any falsification or omission of material facts may cause forfeiture on my part of all rights to EMT certification in the state of California. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as an EMT in California.

Signature of Applicant _________________________________________ Date __________________________

Attach the following documents to the application SF EMS Agency, Attn: Certification

and mail, e-mail, or bring it into the office at: 30 Van Ness Avenue, Suite 3300

San Francisco, CA 94102-6027

|EMT Initial Applicant* |EMT Re-Certification Applicant** |EMT Re-Certification Applicant with |

|[ ] Completed original EMT application form |[ ] Completed original EMT application form |Lapsed Certification |

|[ ] Copy of EMT Basic Course Completion Certificate |[ ] Copy of current State driver’s license |Lapse < 6 months |

|(within the past 2 years) |[ ] Copy of current American Heart Association |[ ] Same as Re-Certification Applicant |

|[ ] Copy of both current NREMT certificate (within |Healthcare Provider CPR card or American Red Cross | |

|the past 2 years) and current NREMT certification |Healthcare Provider CPR card |Lapse of > 6 months but < 12 months |

|card |[ ] Copy of current EMT certification card |[ ] Same as Re-Certification Applicant |

|[ ] Copy of current State driver’s license |[ ] Completed State of California EMT Skills Competency|[ ] CEU requirement is 36 hours |

|[ ] Copy of current American Heart Association |Verification Form |[ ] Copy of NEW of SF EMSA Live Scan form |

|Healthcare Provider CPR card or American Red Cross |[ ] Proof of continuing education training | |

|Healthcare Provider CPR card |Copy of EMT Refresher Course Completion Certificate or |Lapse of > 12 months but < 24 months |

|[ ] Copy of completed Live Scan Fingerprint DOJ and | |[ ] Same as Re-Certification Applicant |

|FBI form (within the past 12 months) |Copies of Continuing Education Unit (CEU) Certificates |[ ] CEU requirement is 48 hours |

|[ ] $149.00 payable to the City and County of San |- 24 hours- |[ ] Copy of both current NREMT certificate and |

|Francisco via check, money order, over the counter |on-line CEUs must say Instructor- |current NREMT certification card |

|debit/credit card, or on-line credit card |based on certificate |[ ] Copy of NEW SF EMSA Live Scan form |

|[ ] Out-of-State applicants are considered Initial |[ ] $110.00 payable to the City and County of San |[ ] $149.00 payable to the City and County of San |

|Applicants and must submit a copy of their |Francisco via check, money order, over the counter |Francisco via check, money order, over the counter |

|Out-of-State EMT Certificate. |debit/credit card, or on-line credit card |debit/credit card, or on-line credit card |

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| |**Out-of-county Re-Certification Applicants |Lapse > 24 months |

| |submit an SF EMSA Live Scan Form and |[ ] Follow EMT Initial Applicant procedures |

| |$149.00 fee | |

FOR EMSA USE ONLY:

Application Received: ( In Person on ________________by______ ( Via E-Mail on __________________ ( Via Mail on _______________ For Initial Applicants: DOJ/FBI Report Submitted _____________________ DOJ/FBI Report Received __________________

Central Registry # E_______________ Issue Date__________________ Expiration Date________________________

CPR Card Expires ________________ NREMT Pass Date _____________ Check/MO $ ________ #___________

Payment: Debit/Credit Card: $________ On-Line Credit Card: $__________ Bill SFFD $ _________________

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