ems0109.docx - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES FIRE FIRE SAFETY INSPECTOR AND OR LIVE FIRE INSTRUCTOR

ems0109.docx - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF...

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OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES FIRE, FIRE SAFETY INSPECTOR, AND / OR LIVE FIRE INSTRUCTOR REINSTATEMENT APPLICATION Incomplete applications WILL NOT be processed. Required fields, as indicated by an asterisk (*), must be completed. (Please print legibly and use black or blue ink.) The purpose of this form is to apply for reinstatement of an expired, voluntarily surrendered, or revoked Fire Instructor, Fire Safety Inspector Instructor, and / or Live Fire Instructor certificate to teach. For information on reinstatement requirements, please visit our webpage at . DO YOU HAVE A CURRENT OHIO EMS OR FIRE CERTIFICATION?* Yes No IF YES, OHIO CERTIFICATION NUMBER* LEGAL LAST NAME* LEGAL FIRST NAME* LEGAL MIDDLE INITIAL SUFFIX HOME ADDRESS (STREET)* P.O. BOX CITY* STATE* ZIP CODE* COUNTY OF RESIDENCE HOME PHONE NUMBER WORK PHONE NUMBER CELL PHONE NUMBER E-MAIL ADDRESS* SECONDARY E-MAIL ADDRESS SOCIAL SECURITY NUMBER* Disclosure of social security number is mandatory pursuant to Ohio Revised Code (R.C.) 3123.50 in furtherance of licensing provision and any other state or federal requirements. DATE OF BIRTH* CERTIFICATION NUMBER* CERTIFICATION EXPIRATION DATE* CERTIFICATION REVOCATION DATE* N/A EXPIRED / REVOKED / SURRENDERED CERTIFICATE(S)* (Select all that apply) FIRE INSTRUCTOR LIVE FIRE INSTRUCTOR FIRE SAFETY INSPECTOR INSTRUCTOR SELECT THE CERTIFICATE(S) YOU WISH TO REINSTATE * (Select all that apply) FIRE INSTRUCTOR LIVE FIRE INSTRUCTOR FIRE SAFETY INSPECTOR INSTRUCTOR ARMED FORCES INFORMATION* Mark at least one response. Using the definition of armed forces provided, check all that apply and provide information requested. "Armed forces" means the armed forces of the United States, including the army, navy, air force, marine corps, coast guard, or any reserve components of those forces; the national guard of any state; the commissioned corps of the United States public health service; the merchant marine service during wartime; such other service as may be designated by congress; or the Ohio organized militia when engaged in full-time national guard duty for a period of more than thirty days. (R.C. section 5903.01) I am a veteran of the armed forces, discharged / released under honorable conditions.
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  • Fall '16
  • Dr.Mah
  • Armed forces

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