Renewal Ems Personnel Recertification/re-Licensure Application Eca, Emt, Emt-I, Emt-P, Lp

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Regulatory Licensing Unit
EMS Certification & Licensing Group
Department of State Health Services
Cash Receipts Branch, MC 2003
P.O. Box 149347
Austin, Texas 78714-9347
(512) 834-6700 FAX (512) 834-6714
RENEWAL EMS Personnel Recertification/Re-Licensure Application
ECA, EMT, EMT-I, EMT-P, LP
APPLICATION SUBMISSION:
Application processing takes approximately 4-6 weeks.
Applicant is not considered certified/licensed until the application is processed and approved.
VISIT OUR WEBSITE FOR MORE INFORMATION:
SECTION 1 – PERSONNEL DATA
TYPE OR PRINT IN BLACK INK
Social Security Number*
Last Name
First Name
Middle Name
List other names you have used (eg. alias, married/maiden, etc.)
Address Street, Apt. Number or PO Box
City
State
Zip
Home Phone
Business Phone
Date of Birth
Driver License Number (include state)
E-mail Address
* Disclosure of your social security number is mandatory under Family Code, Chapter 231.302(c)(1)
Check the level for which you are applying
ECA
EMT
EMT-Intermediate
EMT-Paramedic
Licensed Paramedic
Page 1 of 4
3/25/2015

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