Ems Personnel License Application
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4MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
UEMS USE ONLY
BUREAU OF EMERGENCY MEDICAL SERVICES
EMS PERSONNEL LICENSE APPLICATION
FOR DOH OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE
APPROVED BY/DATE
EMT LICENSE NO.
DATE LICENSED
____________________
DATE APP. REC’D.
EXPIRATION DATE
APPLICANT MUST COMPLETE INFORMATION BELOW
TYPE OR PRINT
CURRENT MO EMS LIC NO.
EXPIRATION DATE
1.
INITIAL LICENSE APP.
IF APPLICABLE
AND
2.
RELICENSURE APP.
3. TYPE OF LICENSE APPLIED FOR (Check One)
EMT-Basic
EMT-Intermediate
EMT-Paramedic
4. CERTIFICATION/EDUCATION USED FOR INITIAL LICENSURE OR RELICENSURE: (PLEASE CHECK ONLY ONE)
EMT-B
EMT-I
EMT-P
EMT-B
EMT-I
EMT-P
NATIONAL REGISTRY
NATIONAL REGISTRY
NATIONAL REGISTRY
CONTINUING
CONTINUING
CONTINUING
EDUCATION
EDUCATION
EDUCATION
(Attach copy of card)
(Attach copy of card)
(Attach copy of card)
5. NAME (LAST, FIRST, MIDDLE INITIAL)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
DAYTIME PHONE NUMBER
M
F
MO____DAY____YR____
E-MAIL ADDRESS (if applicable)
MAILING ADDRESS (STREET)
CITY
STATE
ZIP CODE
COUNTY
6. NAME OF THE EMS AGENCY YOU ARE CURRENTLY WORKING FOR.(If applicable)
7. TYPE OF PRESENT PRIMARY EMS AFFILIATION (IF APPLICABLE)
AMBULANCE SERVICE
UNLICENSED FIRST RESPONDER AGENCY
POLICE DEPARTMENT
LICENSED EMRA
FIRE SERVICE
OTHER
8. Have you ever had administrative licensure action taken against your EMT license in Missouri or any other state?
No
Yes
IF YES, EXPLAIN ON ATTACHED SHEET
9. Has your right to practice in a health care occupation ever been subject to limitation, suspension, or termination?
Yes
No
Not applicable
IF YES, EXPLAIN ON ATTACHED SHEET
10. Have you ever voluntarily surrendered a health care license or certification in any state?
Yes
No
Not applicable
IF YES, EXPLAIN ON ATTACHED SHEET
11. HAVE YOU EVER BEEN FINALLY ADJUDICATED AND FOUND GUILTY, OR ENTERED A PLEA OF GUILTY OR NOLO
CONTENDERE IN A CRIMINAL PROSECUTION UNDER THE LAWS OF ANY STATE OR OF THE UNITED STATES, WHETHER OR
NOT YOU RECEIVED A SUSPENDED IMPOSITION OF SENTENCE FOR ANY CRIMINAL OFFENSE?
Yes
No
IF YOU HAVE ANSWERED YES TO THE ABOVE QUESTION YOU MUST ATTACH TO YOUR APPLICATION A CERTIFIED COPY
OF ALL CHARGING DOCUMENTS (SUCH AS COMPLAINTS, INFORMATIONS OR INDICTMENTS), JUDGMENTS AND
SENTENCING INFORMATION AND ANY OTHER INFORMATION YOU WISH CONSIDERED.
12. I HEREBY CERTIFY THAT:
A.
I am able to speak, read and write the English language.
B.
I do not have a physical or mental impairment which would substantially limit my ability to perform the essential functions of an
emergency medical technician with or without a reasonable accommodation.
C.
This application contains no misrepresentations or falsifications and the information given by me is true and complete to the best of my
knowledge. I further certify that I have both the intention and the ability to comply with the regulations promulgated under Chapter 190,
RSMo
D.
I have been a resident of Missouri for five (5) consecutive years prior to the date on the application or I have attached to the application
at least two (2) completed fingerprint cards supplied by the EMS Bureau.
IF RELICENSING USING CONTINUING EDUCATION, PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM
APPLICANT’S SIGNATURE
DATE
WARNING: In addition to licensure action, anyone who knowingly makes a false statement in writing with the intent to mislead a public
servant in the performance of his official duty may be guilty of a class B misdemeanor, Missouri Statutes 575.060.
Mail application to: Bureau of EMS, P.O. Box 570, Jefferson City, MO 65102
MO 580-0988 (R 11/07)
EMS-3
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