Fillable Sc Dhec Bureau Of Ems Certification Application Form printable pdf download

Sc Dhec Bureau Of Ems Certification Application Form

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SC DHEC Bureau of EMS

Certification Application Form

Please return completed form and required documents via email to

emscertifications@dhec.sc.gov

NOTE: Form D-2352 is required for candidates applying with an Out of State certification.

SSN (Last 4 #s)

Out of State Certification Number

National Registry Certification Number

-or-

National Registry Cert. Exp. Date

Out of State Expiration Date

CIS Profile Userid

Level of Certification (Check One)

PARAMEDIC

EMT

AEMT

SPECIAL PURPOSE EMT (RN)

First Name

Middle Initial

Last Name

Phone Number

By initialing here _______ you attest that you have created a SC Credentialing Information System (CIS) profile as outlined in the

Reciprocity Guidelines Packet. Your SC certification will be mailed to the address listed on your CIS profile. You may find CIS login

instructions on our portal, , or by going to

Attach the Following Credentials

Out of State Credential

BLS (CPR) Credential

Attach a copy (front and back) of a valid / current BLS Credential

National Registry Credential

BLS card MUST be one of the following:

Attach a copy of your current Out of State or

NREMT Credential

AHA: BLS for the Healthcare Professional

ARC: CPR for the Professional Rescuer

(Out of State Credential must have at least 1 year remaining)

ASHI: CPR Pro

SLED and FBI Criminal Background Check

Additional Credential for Paramedics

Attach a copy of your Safran Morpho Trust USA

fingerprint receipt

Advanced Cardiac Life Support (ACLS) Credential

Attach a copy (front and back) of your valid current ACLS Credential

You may call go to or

ACLS credential MUST be one of the following:

call 1-866-254-2366 to schedule an appointment.

AHA: ACLS

o Check here if you followed the out-of-state background

instructions.

ASHI: ACLS

SC DHEC EMS ORI #: SC920111Z

Applicant privacy rights can be found at fbi.gov

I hereby affirm that all statements on this form are true and correct, including the copies of all cards,

certifications, and attachments. It is understood that false statements or documents may be sufficient cause for denial/revocation of my EMT

credential by SC DHEC. It is also understood that SC DHEC may conduct a full audit of all activities listed on this form at any time.

Your Signature (Must be original signature) & Date Signed

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

DHEC 2351 (03/2017)

Sc Dhec Bureau Of Ems Certification Application Form

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