Ohio
|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |DIVISION OF EMERGENCY MEDICAL SERVICES | |
| | | |
| |EMFTS COMMITTEE MEMBER APPLICATION | |
| |
|LAST NAME |FIRST NAME |MIDDLE INITIAL |
| | | |
|STREET ADDRESS |CITY |STATE |ZIP |
| | | | |
|COUNTY |TELEPHONE # | WORK HOME |CELL # |FAX # |
| | | | | |
|E-MAIL |
| |
| CURRENT BOARD MEMBER | PROGRAM DIRECTOR (for an approved, accredited or chartered training institution) |
|CHECK THE EMFTS COMMITTEE(S), AD-HOC COMMITTEE(S), OR SUBCOMMITTEE(S) THAT YOU ARE INTERESTED IN SERVING. |
| CRITICAL CARE | EDUCATION | EMS SYSTEM DEVELOPMENT |
| EMS CHILDREN (EMS-C) | HOMELAND SECURITY | MEDICAL OVERSIGHT |
| MEDICAL TRANSPORTATION | RURAL EMS | |
| OTHER |
| |
|All committee / subcommittee / ad-hoc committee members are expected to attend at least three-fifths of regular scheduled meetings. |
|Members that fail to do so may forfeit their position. |
|LIST ANY EMS, FIRE, MEDICAL TRANSPORTATION, OR RELATED ENTITIES WITH WHICH YOU ARE EMPLOYED AND / OR AFFILIATED. |
|(EMS / fire organizations, ambulance services, hospitals, educational institutions, etc.) |
| |
|LIST ANY PROFESSIONAL LICENSES AND / OR CERTIFICATIONS YOU CURRENTLY HOLD. INCLUDE LICENSE AND / OR CERTIFICATE NUMBERS. |
| |
|LIST ANY MEMBERSHIPS OR AFFILIATIONS WITH PROFESSIONAL ASSOCIATIONS. |
| |
|STATE WHY YOU WOULD LIKE TO SERVE ON THE SELECTED COMMITTEE(S), AD-HOC COMMITTEE(S), AND / OR SUBCOMMITTEE(S). |
| |
|APPLICANT SIGNATURE |DATE |
|X | |
| |
|Submit the completed application along with a current curriculum vitae or resume to: |
|MAIL |FAX |E-MAIL |
|Ohio Department of Public Safety |(614) 466-9461 |DEMS@dps. |
|Division of Emergency Medical Services | | |
|ATTN: EMFTS Board Secretary | | |
|P.O. Box 182073 | | |
|Columbus, Ohio 43218-2073 | | |
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