Ems Personnel License Application Page 4
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DECLARATION OF CEUS
# OF HRS
TRAINING ENTITY ACCREDITATION #,
NAME OR TYPE
DIV OR
# OF HRS
ELECTIVE
CECBEMS APPROVAL #, OR OTHER
2
OF COURSE
MODULE
CORE
ACCREDITING AGENCY
2
2
2
(ACLS, PALS, BTLS, MONA, ACEP, ETC
.)
2
TOTAL HOURS
COPY THIS SHEET IF NECESSARY
IF RELICENSING USING CONTINUING EDUCATION, I HEREBY CERTIFY THAT:
I have successfully completed the required continuing education in accordance with state regulations.
1.
I have attached a list of these Continuing Education Units
2.
I am in possession of documentation of the required continuing education and will make all records available to the Missouri Department
3.
of Health and Senior Services upon request under penalty of license action, up to and including revocation.
EMT-B and EMT-I applicants must attach a copy of current CPR card.
4.
5.
EMT-P must attach copy of current ACLS card.
APPLICANT’S SIGNATURE
DATE
MO 580-0988 (R 11/07)
EMS-3
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