Doh-4010 Application For Aemt Rapid Recertification
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1
2Application for
NEW YORK STATE DEPARTMENT OF HEALTH
AEMT Rapid Recertification
Bureau of Emergency Medical Services
Please print legibly in capital letters or type. Put only one letter or number in each box.
(Please retain this number for future reference.)
Course Number
This form should only be used for
AEMT Rapid Recertification, and
X
Check if this application is for:
Original Certification
Recertification
must be attached to a Course
Memorandum and submitted by an
approved course sponsor.
EMS Identification Number (if you have one)
Both sides of this form must be
Write your NYS EMS number in this space
completed and signed.
Last Name
First Name and M.I.
Check this box if your name as stated above has changed or is spelled differently than it is on your current
EMS card. On the line provided below, enter your name as it appears on your current EMS card.
Address
Number and Street
(Skip one space between number and street)
City
State
Zip Code
County
Date of Birth
MONTH
DAY
YEAR
Social Security #
Sex
On Teaching
Yes
(Enter M or F)
No
Faculty
If you belong to an EMS agency, please indicate the code in the box(es) below.
Primary EMS
Secondary EMS
Agency
Agency
Practical Skills Exam Date
NYS Written Exam Date
Day Telephone #
MONTH
DAY
YEAR
MONTH
DAY
YEAR
Personal Affirmation
Read carefully before signing
I do affirm that, in accordance with the requirements of 10 NYCRR 800, I have NOT been convicted of any misdemeanors or felonies. I
understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to
certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.
Do not sign this if you have any convictions.
I hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as
applicant. I further understand that offering or providing false information on this document may constitute a crime under the penal law
and may subject any certification to revocation or other Department action
Signature of Applicant
Date
DOH-4010 (10/04) page 1 of 2
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