Georgia Ems Instructor Renewal

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GEORGIA OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA
Form C-11-B
EMS INSTRUCTOR RENEWAL
RENEWAL PERIOD ______________
To maintain your license as an EMS instructor you must complete this form and submit the appropriate supporting
documents to the Office of Emergency Medical Services by December 31 of every odd year.
Instructor Name:
Instructor Number:
Address:
Level of Licensure:
License Number:
Phone:
E-mail Address:
Affiliate Institution or Agency:
Address:
ACTIVE PRACTICE
I do hereby affirm that I have taught a minimum of twenty (20) hours per year of EMS instruction in an approved course as
required in DPH Rules and Regulations for EMS 511-9-2 for this renewal period.
Signature: ______________________________________________________ Date: __________________________
CONTINUING EDUCATION
I do hereby affirm that I have successfully completed 24 hours of EMS Instructor continuing education as required in DPH
Rules and Regulations for EMS 511-9-2 for this renewal period.
Signature: ______________________________________________________ Date: __________________________
By affixing my signature above, I affirm that the information provided on this form is correct to the best
of my knowledge and that any fraudulent entry may be considered as sufficient cause for any
rejection or subsequent revocation.
FORM C-11-B: EMS INSTRUCTOR RENEWAL
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