ems0088.doc - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS APPLICATION REINSTATEMENT All Information MUST be included

ems0088.doc - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF...

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OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS APPLICATION - REINSTATEMENT All Information MUST be included. Incomplete applications WILL NOT be processed. (Please print legibly and use black or blue ink.) LEGAL LAST NAME LEGAL FIRST NAME LEGAL MIDDLE INITIAL SOCIAL SECURITY # 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 HOME ADDRESS P.O. BOX CITY STATE HOME PHONE # WORK PHONE # COUNTY OF RESIDENCE ZIP CODE E-MAIL ADDRESS SECONDARY E-MAIL ADDRESS EXPIRED CERTIFICATION # CERTIFICATION EXPIRATION DATE LEVEL OF CERTIFICATION PREVIOUSLY HELD FIRST RESPONDER EMT BASIC EMT INTERMEDIATE PARAMEDIC LEVEL OF REINSTATEMENT FIRST RESPONDER EMT BASIC EMT INTERMEDIATE PARAMEDIC 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

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