Form Dhec 2352 - Out-Of-State Reciprocity Verification Form

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Out-Of-State Reciprocity Verification Form
South Carolina Department of Health and Environmental Control
Division of EMS & Trauma
Section I: To be completed by the candidate. It is the candidates responsibility to send this form to each state or
territory they have been licensed, certified, or registered as an emergency medical services provider (make copies as
necessary).
Name: _______________________________________________ SSN: _____________________________________
Mailing Address: __________________________________________________________________________________
City / State / Zip Code _____________________________________________________________________________
Phone Number(s) _________________________________________________________________________________
Certification Number ____________________________ Level of Certification _________________________________
****************************************************************************************************************************************
Section II: To be completed by the state certification agency
The above individual has applied for reciprocity in South Carolina. Please complete the following and either fax the form
to (803-545-4563 attn: EMS Division) -OR- mail to SC DHEC EMS Division, 2600 Bull Street, Columbia, SC 29201 or
email to emscertifications@dhec.sc.gov.
1)
Indicate current certification level of candidate: ___________________________________________________
2)
Candidates certificate expiration date: __________________________________________________________
3)
Has this candidate ever had his/her certification revoked or suspended? _______________________________
(If Yes attach details.)
4)
Has this candidate ever been convicted of a felony? [ ] Yes, [ ] No, [ ] Unknown
(If Yes attach details.)
5)
Was this candidate's certification issued based on reciprocity from another state? ________________________
If Yes, Which state: ________________________________ When: __________________________________
6)
Any reason why this candidate should Not be granted reciprocity? ____________________________________
(If Yes attach details.)
____________________________________
______________________________
________________________
Name (Print) of state official completing form
Title
Your State
___________________________________
_____________________________________
Signature of state official completing form
Telephone Number
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 2352 (06/2015)

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