Renewal Ems Personnel Recertification/re-Licensure Application Eca, Emt, Emt-I, Emt-P, Lp Page 4

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Name

Social Security Number

SECTION 6 – CRIMINAL/DISCIPLINARY HISTORY – Everyone MUST answer “YES or NO” to ALL questions below.

Failure to report any limitation, suspension and revocation of a license and/or any convictions(s), deferred adjudication/disposition case information may

result in disciplinary action and/or denial/decertification against your Texas EMS personnel certification or licensure. DO NOT answer, “Yes” if you only

have minor traffic violations, e.g. speeding tickets or minor parking violations. Driving While Intoxicated, Reckless Driving, or Obstruction of a Highway

Passageway offenses are not considered minor traffic violations.

Have you ever been subject to limitation, suspension, or revocation of a

Yes

license (not driver's license), including your right to practice in a

healthcare occupation?

Have you ever surrendered any type of license (not driver's license) in any

Yes

state or to a state agency that had issued you a license?

Have you ever been denied any type of license (not driver's license) in

Yes

any state or by a state agency?

For the remaining question listed below, please DO NOT include any criminal history reported on any previous application for

EMS Certification or Paramedic Licensure.

Have you ever been placed on deferred adjudication, deferred disposition

Yes

(pretrial diversion) for a felony or misdemeanor since your last EMS

application submission?

Have you ever been convicted of a felony since your last EMS application

Yes

submission?

Have you ever been convicted of a misdemeanor since your last EMS

Yes

application submission?

Do you need to report new criminal history information since your last

Yes

EMS application submission?

Indicate offense(s) committed & court case/cause number(s):

Dates(s) of conviction(s) and/or deferred adjudication(s)

SECTION 7 – SIGNATURE AND DATE

I swear or affirm that all information on this application is true and correct. I further certify by signature hereon, that I am authorized to execute this

document. I am not delinquent in the payment of any child support owed under Chapter 232, Family Code. I further certify that I have read, understood, and

agree to abide to Chapter 773 of the Health and Safety Code and the applicable provisions of 25 TAC, Chapter 157, and agree to abide by them.

Signature of Applicant ___________________________________________

Date

If you are granted certification/licensure you will be responsible for reporting any changes to the information you provide on this form. The Name/Address

Change form is available at the following website:

PRIVACY NOTIFICATION

With a few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to

receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be

incorrect. See for information on Privacy Notification. (Reference Government Code, Section 522.021, 522.023 and 559.004)

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3/25/2015