Subject - State of Ohio EMS
|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |
| |DIVISION OF EMERGENCY MEDICAL SERVICES | |
| | | |
| |APPLICATION FEE / DISCIPLINARY PAYMENT REMITTANCE | |
| |
|All Information MUST be included. Incomplete applications WILL NOT be processed. |
|(Please print legibly and use black or blue ink.) |
|APPLICANT LEGAL LAST NAME |LEGAL FIRST NAME |LEGAL MIDDLE INITIAL |
| | | |
|HOME ADDRESS |P.O. BOX |
| | |
|CITY |STATE |ZIP CODE |COUNTY OF RESIDENCE |
| | | | |
|HOME PHONE |WORK PHONE |
| | |
|CERTIFICATION LEVEL |CERTIFICATION EXPIRATION DATE |CERTIFICATION NUMBER |
| | | |
|SOCIAL SECURITY NUMBER |Disclosure of social security number is mandatory pursuant to Ohio Revised Code 3123.50 in |
| |furtherance of licensing provisions and any other state or federal requirements. |
| | |
| | |
|Application Fee (Dept. 703) |Amount |
| | |
|Disciplinary Payment | |
|EMS Service Provider (Dept. 702) |Amount |
|Fire Service Provider (Dept. 702) |Amount |
|APPLICANT SIGNATURE |DATE |
|X | |
Please submit Check or Money Order made payable to:
Ohio Treasurer of State
Please mail all payments to:
Ohio Department of Public Safety
Attn: Remittance Processing
P.O. BOX 16520
Columbus, Ohio 43216-6520
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- state of ohio certification verification
- state of ohio education department
- state of ohio teacher contracts
- state of ohio teaching positions
- state of ohio teaching jobs
- state of ohio certification list
- state of ohio board of education
- state of ohio dept of education
- state of ohio department of education
- state of ohio ems verification
- state of nevada ems certification verification
- state of ohio bureau of workers compensation