ems5922.docx - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS INSTRUCTOR REINSTATEMENT APPLICATION Incomplete applications

ems5922.docx - OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF...

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OHIO DEPARTMENT OF PUBLIC SAFETY DIVISION OF EMERGENCY MEDICAL SERVICES EMS INSTRUCTOR REINSTATEMENT APPLICATION Incomplete applications WILL NOT be processed. Required fields, denoted by an asterisk (*), must be completed. (Please print legibly and use black or blue ink.) The purpose of this form is to reinstate an Assistant EMS Instructor certificate to teach. For information on certification requirements, please visit our webpage at . LEGAL LAST NAME* LEGAL FIRST NAME* LEGAL MI 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 # 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* LICENSE / CERTIFICATE NUMBER* 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. Year of discharge / release I am a current member of the armed forces. I am a spouse of a current member of the armed forces or a veteran, discharged / released under honorable conditions. Year of veteran’s discharge / release I am a surviving spouse of a service member or veteran, discharged / released under honorable conditions. Year of veteran’s discharge / release None of the above. You must answer the following questions for your application to be considered:*
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  • Fall '16
  • Dr.Mah
  • EMS Instructor

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