"Emergency Medical Services Certification Application Form" - Nevada

Emergency Medical Services Certification Application Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

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Amt Rec’d:
Course #:
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Check/MO:
NREMT #:
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
EMERGENCY MEDICAL SYSTEMS
Receipt No.:
NV EMS #:
EMERGENCY MEDICAL SERVICES CERTIFICATION APPLICATION
This application for certification must be completed and submitted to the Division of Public and
Behavioral Health EMS and must be accompanied by a check or money order for $24.00** payable to the
Nevada Division of Public and Behavioral Health. Please indicate below if this is an initial or a renewal and
include the documentation requested for that process.
 Initial Certification
 Certification Upgrade
A. National Registry Certification OR
A. National Registry Certification
Course Completion Report for EMR
B. Copy of Healthcare Provider CPR
B. Copy of Healthcare Provider CPR
Provider Card
Provider Card
C. For Paramedics, Copy of ACLS, PALS
C. For Paramedics, Copy of ACLS, PALS
and ITLS Provider Cards.
and ITLS Provider Cards
 EMD
 EMR
 EMT
Certification Level you are applying for:
 Advanced EMT
 Paramedic
 EMS Instructor
 Immunization
Endorsements you are applying for:
 Critical Care Paramedic  Community Paramedic
1. Applicant Information
_____________________________________________________________________________________
___________________________________
Last Name
First Name
Middle Name
Social Security Number
_____________________________________________________________________________________
___________________________________
Mailing Address
Date of Birth
 Female
Male
_____________________________________________________________________________________
City
County
State
Zip Code
(________)____________________
(________)____________________
_____________________________________________________
Primary Phone
Secondary Phone
Email Address
2. Employment Information
__________________________________________________
______________________________________
Employer Name
Employer Phone
____________________________________________________________________________________________
Address
City
State
Zip
2. Military Information
 Yes
 No
1.
Have you ever served in the Armed Forces?
a.
If yes, please complete:
__________________________
_________________________
Branch of Military Service
Dates of Service
Amt Rec’d:
Course #:
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Check/MO:
NREMT #:
DIVISION OF PUBLIC AND BEHAVIORAL HEALTH
EMERGENCY MEDICAL SYSTEMS
Receipt No.:
NV EMS #:
EMERGENCY MEDICAL SERVICES CERTIFICATION APPLICATION
This application for certification must be completed and submitted to the Division of Public and
Behavioral Health EMS and must be accompanied by a check or money order for $24.00** payable to the
Nevada Division of Public and Behavioral Health. Please indicate below if this is an initial or a renewal and
include the documentation requested for that process.
 Initial Certification
 Certification Upgrade
A. National Registry Certification OR
A. National Registry Certification
Course Completion Report for EMR
B. Copy of Healthcare Provider CPR
B. Copy of Healthcare Provider CPR
Provider Card
Provider Card
C. For Paramedics, Copy of ACLS, PALS
C. For Paramedics, Copy of ACLS, PALS
and ITLS Provider Cards.
and ITLS Provider Cards
 EMD
 EMR
 EMT
Certification Level you are applying for:
 Advanced EMT
 Paramedic
 EMS Instructor
 Immunization
Endorsements you are applying for:
 Critical Care Paramedic  Community Paramedic
1. Applicant Information
_____________________________________________________________________________________
___________________________________
Last Name
First Name
Middle Name
Social Security Number
_____________________________________________________________________________________
___________________________________
Mailing Address
Date of Birth
 Female
Male
_____________________________________________________________________________________
City
County
State
Zip Code
(________)____________________
(________)____________________
_____________________________________________________
Primary Phone
Secondary Phone
Email Address
2. Employment Information
__________________________________________________
______________________________________
Employer Name
Employer Phone
____________________________________________________________________________________________
Address
City
State
Zip
2. Military Information
 Yes
 No
1.
Have you ever served in the Armed Forces?
a.
If yes, please complete:
__________________________
_________________________
Branch of Military Service
Dates of Service
5. Certification / Licensure History
 Yes
 No
1.
Are you currently registered with the National Registry of EMT’s?
b.
If yes, please complete:
____________________ ____________________ _______________
National Registry No.
Certification Level
Expiration Date
 Yes
 No
2.
Have you ever been certified/licensed as an EMS Provider in any other state?
_________________________________________________ _________ __________________ __________________ __________________
Issuing Authority
State
Type of Cert / License Certification Number
Expiration Date
_________________________________________________ _________ __________________ __________________ __________________
Issuing Authority
State
Type of Cert / License Certification Number
Expiration Date
6. Child Support Information
 I am not subject to a court order for the support of a child.
 I am subject to a court order for the support of one or more children and am in compliance with the order or am in
compliance with a plan approved by the District Attorney or other public agency enforcing the order for the repayment of the
amount owed pursuant to the order; or
 I am subject to a court order for the support of one or more children and am not in compliance with the order or a plan
approved by the District Attorney or other public agency enforcing the order for the repayment of the amount owed pursuant
to the order.
7. Applicant Certification
I, the above applicant, hereby certify that all statements made in this application are true and correct to the best of my
knowledge. I understand and agree that any misstatements of material facts herein may cause forfeiture on my part of all
rights to certification by the State of Nevada.
_____________________________________
_________________
Signature of Applicant
Date
OFFICIAL USE ONLY
Reviewed By: ________________________
Date: ___________________
[ ] Approved
[ ] Denied
Certification Level:
[ ] EMR
[ ] EMT
[ ] Advanced EMT
[ ] Paramedic
_______________________
Expiration Date
Endorsement(s):
[ ] Critical Care Paramedic
[ ] Community Paramedicine
[ ] EMS Instructor
[ ] Immunization
_______________________
Date Printed
Denial Reason, if applicable: ___________________________________________________________________
FINGERPRINT BACKGROUND WAIVER
As an applicant who is subject of a Federal Bureau of Investigation (FBI) fingerprint-based criminal
history record check for a noncriminal justice purpose you have certain rights which are discussed
below.
1. You must be notified by the Emergency Medical Systems Program, of the Nevada Division of
Public and Behavioral Health, that your fingerprints will be used to check the criminal history
records of the FBI and the State of Nevada.
2. If you have a criminal history record, the officials making a determination of your suitability for
the job, license or other benefits for which you are applying must provide you the opportunity to
complete or challenge the accuracy of the information in the record. You may review and
challenge the accuracy of any and all criminal history records which are returned to the
submitting agency. The proper forms and procedures will be furnished to you by the Nevada
Department of Public Safety, Records Bureau upon request. If you decide to challenge the
accuracy or completeness of your FBI criminal history record, Title 28 of the Code of Federal
Regulations Section 16.34 provides for the proper procedure to do so:
16.34 – Procedure to obtain change, correction or updating of identification records.
If, after reviewing his/her identification record, the subject thereof believes that it is
incorrect or incomplete in any respect and whishes changes, corrections or updating of
the alleged deficiency, he/she should make application directly to the agency which
contributed the questioned information. The subject of a record may also direct her/her
challenge as to the accuracy or completeness of any entry on his/her record to the FBI,
Criminal Justice Information Service (CJIS) Division ATTN: SCU, Mod. D-2, 1000
Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to
the agency which submitted the data requesting that the agency to verify or correct the
challenged entry. Upon the receipt of an official communication directly from the
agency which contributed the original information, the FBI CJIS Division will make any
changes necessary in accordance with the information supplied by the agency.
3. Based on 28 CFR
§
50.12 (b), officials making such determinations should not deny the
license or employment based on information in the record until the applicant has been afforded
a reasonable time to correct or complete the record or has declined to do so.
4. You have the right to expect that officials receiving the results of the fingerprint-based criminal
history record check will use it only for authorized purposes and will not retain or disseminate it
in violation of federal or state statute, regulation or executive order, or rule, procedures or
standard established by the National Crime Prevention and Privacy Compact Council.
5. I hereby authorize the Emergency Medical Systems Program, of the Nevada Division of Public
and Behavioral Health, to submit a set of my fingerprints to the Nevada Department of Public
Safety Records Bureau for the purpose of accessing and reviewing State of Nevada and FBI
criminal history records that may pertain to me.
In giving this authorization, I expressly understand that records may include information
pertaining to notations of arrest, detainments, indictments, information or other charges
for which the final court disposition is pending or is unknown to the above referenced
agency. For records containing final court disposition information, I understand that the
release may include information pertaining to dismissals, acquittals, convictions,
sentences, correctional supervision information and information concerning the status of
my parole or probation when applicable.
6. I hereby release from liability and promise to hold harmless under any and all causes of legal
action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my
criminal history records search and provided information to the submitting agency for any
statement(s), omission(s), or infringement(s) upon my current legal rights. I further release
and promise to hold harmless and covenant not to sue any persons, firms, institutions or
agencies providing such information to the State of Nevada on the basis of their disclosures. I
have signed this release voluntarily and of my own free will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar
process, shall for all purposes be as valid as the original.
In consideration for processing my application, I, the undersigned, whose name and signature is
voluntarily appears below; do hereby and irrevocably agree to the above.
APPLICANT’S NAME:
__________________________________________________
APPLICANT’S ADDRESS:__________________________________________________
APPLICANT SIGNAURE: __________________________________________________
DATE SIGNED:
________________________
SUBMITTING AGENCY:
Emergency Medical Systems Program
Nevada Division of Public and Behavioral Health
4150 Technology Way, Suite 101
Carson City, Nevada 89706
(775) 687-7590
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