"Emergency Medical Services (EMS) Systems Military Licensure Request" - Illinois

Emergency Medical Services (EMS) Systems Military Licensure Request is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

Form Details:

  • Released on May 1, 2012;
  • The latest edition currently provided by the Illinois Department of Public Health;
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  • Fill out the form in our online filing application.

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State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Military Licensure Request
Instruction for Completing the Military Licensure Request
PURPOSE: This form shall be completed by military medics seeking licensure as an emergency medical technician (EMT) in
the state of Illinois. Requests for licensure of medics are determined on a case-by-case basis.
Attach the following items to the completed application:
• Training course curriculum
• Course completion certificate(s)
• Documentation of clinical experience
• Letter of verification of documentation from a military educator
• Current CPR card
Submit the completed application, fee(s) and other required documentation to:
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Attn: Military Licensure
Springfield, Illinois 62701
Upon review of application and necessary documentation, a determination will be made as to eligibility of level of EMT license
and whether or not a state of Illinois exam for that level will be required.
If you have any questions, contact the Illinois Department of Public Health, Division of Emergency Medical Systems and
Highway Safety, at 217-785-2080.
State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Military Licensure Request
Instruction for Completing the Military Licensure Request
PURPOSE: This form shall be completed by military medics seeking licensure as an emergency medical technician (EMT) in
the state of Illinois. Requests for licensure of medics are determined on a case-by-case basis.
Attach the following items to the completed application:
• Training course curriculum
• Course completion certificate(s)
• Documentation of clinical experience
• Letter of verification of documentation from a military educator
• Current CPR card
Submit the completed application, fee(s) and other required documentation to:
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Attn: Military Licensure
Springfield, Illinois 62701
Upon review of application and necessary documentation, a determination will be made as to eligibility of level of EMT license
and whether or not a state of Illinois exam for that level will be required.
If you have any questions, contact the Illinois Department of Public Health, Division of Emergency Medical Systems and
Highway Safety, at 217-785-2080.
State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Military Licensure Request
All information must be completed or the application will be returned unapproved.
Applicant Name _______________________________________________________________________________________
Address _________________________________________________________
Apt. Number _______________________
City/State ________________________________________________________
ZIP Code __________________________
Phone Number _________________________
E-mail Address _______________________________________________
Date of Birth ___________________________
Social Security Number ________________________________________
Personal History Statement:
Have you ever been convicted or plead guilty of any felony offense?
Yes
No
If yes, provide an explanation, in your own words, of the nature of the offense. An additional fee and authorization for release
of information must be submitted to the Department to obtain a criminal history report from the Illinois State Police or other
law enforcement agency. The release form and fee schedule can be found at www.idph.state.il.us/ems.
Child Support Statement:
Are you more than 30 days delinquent in complying with a child support order?
Yes
No
Under penalty of perjury, I declare that I have reviewed the application and all supporting documents submitted by me in
connection with this request and, to the best of my knowledge, they are correct and complete.
________________________________________________________
______________________________________
Signature of Applicant
Date
I attest that the above named applicant has completed all didactic, clinical and skill competencies required under the National
EMS Education Standards. I recommend this applicant be licensed at the level determined by the Department.
________________________________________________________
______________________________________
Military Educator Signature
Date
Reviewed and Approved by
________________________________________________________
______________________________________
Regional EMS Coordinator
Date
Submit the completed application, fee(s) and other required documentation to:
Illinois Department of Public Health
Division of Emergency Medical Systems and Highway Safety
422 South Fifth Street, Third Floor
Attn: Military Licensure
Springfield, Illinois 62701
IOCI 12-699
Printed by Authority of the State of Illinois
P.O.#3312159
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