Emergency Medical Services (EMS)
Inactive Request
All areas must be completed or the application will be returned unapproved.
Applicant Name
Address
Apt. Number
City/State
ZIP Code
Phone
E-mail
EMT- B
A-EMT / EMT-1
Paramedic
ECRN
TNS
PHRN
Level of License:
Illinois license enclosed
License Number
I have attached my written request to the EMS medical director for inactive status. I understand that during my inactive period, I
will not function as an EMS provider at any level in Illinois.
Signature of Applicant
Date
EMS SYSTEM/REMSC:
Inactive re-licensure requirements are:
Current
Not current (please attach explanation)
License attached
EMS Medical Director / REMSC Signature
Date
System Number
CENTRAL OFFICE
Inactive request processed on:
Make a copy of all materials for your records prior to submitting the information to:
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
IOCI 16-156
Emergency Medical Services (EMS)
Inactive Request
All areas must be completed or the application will be returned unapproved.
Applicant Name
Address
Apt. Number
City/State
ZIP Code
Phone
E-mail
EMT- B
A-EMT / EMT-1
Paramedic
ECRN
TNS
PHRN
Level of License:
Illinois license enclosed
License Number
I have attached my written request to the EMS medical director for inactive status. I understand that during my inactive period, I
will not function as an EMS provider at any level in Illinois.
Signature of Applicant
Date
EMS SYSTEM/REMSC:
Inactive re-licensure requirements are:
Current
Not current (please attach explanation)
License attached
EMS Medical Director / REMSC Signature
Date
System Number
CENTRAL OFFICE
Inactive request processed on:
Make a copy of all materials for your records prior to submitting the information to:
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
IOCI 16-156