Form Ioci 12-234 - Emergency Medical Services (Ems) Systems Independent Renewal - Illinois Department Of Public Health Page 2
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1
2State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Independent Renewal
All areas must be completed or the application will be returned unapproved.
PURPOSE: This form shall be completed by an individual EMS provider denied relicensure by an EMS system/EMS medical
director or individuals not affiliated with or functioning in an Illinois approved EMS system. Independent license renewals shall
be processed by the Illinois Department of Public Health.
Applicant Name _______________________________________________________________________________________
Address ________________________________________________________________ Apt. Number _________________
City/State _______________________________________________________________ ZIP Code ___________________
Address Change ____________________________________________________________________________________
❑
Phone Number _________________________________ E-mail Address ________________________________________
Level of License:
❑
FRD
❑
EMT-B
❑
EMT-I
❑
EMT-P
❑
ECRN
❑
TNS
❑
PHRN
❑
EMD
License ID Number ____________________________________________
Expiration Date of Current License: ________/_________/_________
Have you operated under an EMS system? If so, what system number? ___________
Personal History Statement:
Have you ever been convicted or plead guilty of any felony offense?
❑
Yes
❑
No
If yes, provide an explanation, in your own words, of the nature of the offense. An additional fee and authorization for release
of information must be submitted to the Department to obtain a criminal history report from the Illinois State Police or other
law enforcement agency. The release form and fee schedule can be found at
Child Support Statement:
Are you more than 30 days delinquent in complying with a child support order?
❑
Yes
❑
No
Under penalty of perjury, I declare that I have reviewed the application and all supporting documents submitted by me in
connection with this request and, to the best of my knowledge, they are correct and complete.
________________________________________________________
______________________________________
Signature of Applicant
Date
Allow at least four weeks to process your renewal request and, if approved, issuance of your Illinois license. If you have any
questions, contact the Illinois Department of Public Health, Division of Emergency Medical Systems and Highway Safety, at
217-785-2080.
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
IOCI 12-234
Printed by Authority of the State of Illinois
P.O.#3312154
20M
12/11
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