Application for Emergency Medical Services CertificationApplication for Emergency Medical Services Certification
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NEW YORK STATE DEPARTMENT OF HEALTH

Application for Emergency Medical
Services Certification

Bureau of Emergency Medical Services

Please print legibly in capital letters or type. Put letter or number in each box.
Course Number

(Please retain this number for future reference)

Check if this application is for:

Original Certification

Recertification

(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

Last Name

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)

Address
Number and Street

(Skip one space between number and street)

City

State

Zip Code

County

Date of Birth

Month

Social Security

Sex

X X X X X

Day

Year

On Teaching Faculty

(Enter M or F)

YES

NO

If you belong to a