Registration For Emergency Medical Technicians' Exam Form
Download a blank fillable Registration For Emergency Medical Technicians' Exam Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Registration For Emergency Medical Technicians' Exam Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Registration for Emergency Medical Technicians’ Exam
NEW YORK STATE DEPARTMENT OF HEALTH
Test Scheduling Request
Bureau of Emergency Medical Services
BEMS USE ONLY:
Please Print
Name
First Name
MI
Last Name
Address
Street
APT. #
City
State
Zip Code
Address Change
Scheduled for:
Site #:
DRAFT
Exam Level:
CFR
EMT
A-EMT
Critical Care
Paramedic
Instructor Score (mark level)
Student ID #: ____ ____ ____ ____ ____ ____ – ____ – ____ ____ ____ ____ ____ ____ (Get from your instructor or exam ticket)
(Course Number)
(EMT Number)
/
/
Student’s Phone Number: (
)
–
Date of Birth:
Month
Day
Year
Daytime Number
/
/
/
/
Selected Test Date:
Time: 7:00 p.m.
My Original Test Date:
Month
Day
Year
Month
Day
Year
Please Choose Between One of the Following Test Sites
Regional Test Site (RTS) Location:
(Refer to RTS list attached. Select a site and indicate site number here).
It will take between 4-6 weeks to get your test score in the mail.
There is no charge.
Students who have received prior approval for an ADA accommodation may be tested at a Regional Test Site. Please make sure that you
notify us that you have already requested an accommodation.
– OR –
On-Site Scoring Test Site Location: (Not available for CFR Level)
OSS Number
Please refer to the OSS list.
Select the site you wish to register for and place the number of that site in the box to the right.
There is a fee of $20.00 payable to Pro Exam in the form of money order or certified check. No cash, credit cards or personal checks will be
accepted. Payment is to be made at the examination site.
There is NO on-site scoring examination available for CFR Level.
We are not able to test students requiring an ADA accommodation at on-site scoring locations.
/
/
Student’s Signature:
Date:
Month
Day
Year
IMPORTANT!
Requests for test scheduling are due to the Bureau of Emergency Medical Services no later than eight weeks before the scheduled
examination date. See attached schedule for dates and available locations. There is limited seating at these locations and registrations are
taken on a “first come, first served” basis. Some locations fill up rapidly.
Examination registration notices will be mailed to you approximately two weeks prior to the test date.
Please mail this completed form to:
OR
Fax to:
New York State Department of Health
(518) 402-0985
Bureau of Emergency Medical Services
Attn: Certification
875 Central Ave
If you are registering for an exam and you have a failure letter
Albany, NY 12206-1388
Attn: Certification Unit
from on-site scoring, you must include the letter with this form.
DOH-4245 (6/13)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form B - Authorization For Emergency Medical Care - Kansas Department Of Health And Environment
Legal
Form K-wc 96 - Registration For Access To Electronic Records Form - Kansas Department Of Labor
Legal
Related Categories
Parent category: Legal