Form Ioci 12-234 - Emergency Medical Services (Ems) Systems Reactivation Request Form - Illinois Department Of Public Health

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State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Reactivation Request
All areas must be completed or the application will be returned unapproved.
Applicant Name ______________________________________________________________________________________
Address ______________________________________________________________ Apt. Number __________________
City/State_____________________________________________________________ ZIP Code _____________________
Phone Number __________________________________ E-mail Address _______________________________________
Address Change
Level of License:
EMT-B
EMT-I
EMT-P
ECRN
TNS
PHRN
LI
License Number ___________________________________________
I have attached my written request to the EMS medical director for license reactivation.
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
EMS SYSTEM/REMSC:
REACTIVATION STATUS:
The above EMS provider has been examined (physically and mentally) and found capable of functioning with the EMS system.
The individual’s knowledge and clinical skills are at an active level. If the inactive status was based on a temporary disability,
I verify the disability has ceased.
_______________________________________________
_______________________
_______________________
EMS Medical Director / REMSC Signature
Date
System Number
CENTRAL OFFICE:
Reactivation request processed on: _______/________/________
Make a copy of all materials for your records prior to submitting the information to:
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.#3312156
20M
12/11

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