Application For Mississippi State Certification

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APPLICATION FOR MISSISSIPPI STATE CERTIFICATION
Applying for: (check one only in each category)
Complete and mail to:
G New Certification
G EMT-Basic
Division of Emergency Medical Services
G Re-certification
G EMT-Intermediate
Mississippi State Department of Health
G EMT-Paramedic
P.O. Box 1700, Jackson, MS 39215 -1700
Driver
Phone (601)576-7380
Social Security Number:
First Name:
MI:
Last Name:
Mailing Address:
(street)
(city)
(state)
(zip code)
(county)
Sex: Male G
Female G
Phone:
Date of Birth:
Education:
GED/High School
College 1 2 3 4 5 6 (circle highest grade completed)
Mississippi Driver’ s License Number:
Expiration Date:
I am/will be engaged as an
at
whose address is:
(EMT-B, I, P or Driver)
(name of primary employer for this certification)
(street)
(city)
(state)
(zip code)
(county)
(phone)
Full Time G
Part Time G
Volunteer G
I am/will be employed (per this level certification)
National Registry EMT Registration Number:
Expiration Date:
Have you been convicted of a felony since receiving your latest National Registry card? Yes G
No G
COMPLETE THIS SECTION ONLY IF ORIGINAL CERTIFICATION
My training was completed at: (name of school)
In the city and state of :
on the following date:
The lead instructor was:
The Medical Director was (EMT-I/P only)
I am/have been certified in other state(s) as follows:
Candidate’ s Statement and Signature (attesting to the above)
I hereby affirm and declare that the above information is true and correct and that any fraudulent entry may be considered sufficient
cause for rejection or subsequent revocation of state certification.
SIGNATURE of Applicant:
Date:
For Official Use Only - EMT and Driver Certification
Date Received
Driver Course
Expiration of Certification
EMT Level
J. M. C.
Approval for Certification
Date Reciprocity Sent
Comments:
RESET FORM
HELP
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