NEW YORK STATE DEPARTMENT OF HEALTH
Application for Emergency Medical
Bureau of Emergency Medical Services
Please print legibly in capital letters or type. Put letter or number in each box.
(Please retain this number for future reference)
Check if this application is for:
(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
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)
Number and Street
(Skip one space between number and street)
Date of Birth
X X X X X
On Teaching Faculty
(Enter M or F)
If you belong to a