Form DOH-2183 "Application for New York State Emt Reciprocity" - New York

What Is Form DOH-2183?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on April 1, 2013;
  • The latest edition provided by the New York State Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DOH-2183 by clicking the link below or browse more documents and templates provided by the New York State Department of Health.

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Download Form DOH-2183 "Application for New York State Emt Reciprocity" - New York

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NEW YORK STATE DEPARTMENT OF HEALTH
Application for New York State EMT Reciprocity
Bureau of Emergency Medical Services
A. PERSONAL DATA
1. Name
2. Date of Birth
Last
First
M.I.
Month
Day
Year
3. Mailing Address
Street
City
State
Zip
4. Social Security Number
5. Home Phone
Work Phone
(
)
(
)
B. TRAINING/CERTIFICATION – Please attach photocopies of state certifications, CPR card and military training certificates.
1. Name of Certifying Agency (state/military/registry)
2. Expiration Date
Month
Day
Year
3. Certification/Registration/License Number
4. National Registry Number (if applicable)
C. LEVEL OF TRAINING – Please attach photocopies of Certificates of Course Completion, etc.
CFR
EMT
Intermediate
AEMT
Paramedic
Please check one of the following:
I have never held any level of New York State EMS Certification.
I previously held a New York State Certification. My EMT # was:
I currently hold a New York State Certification. My EMT # is:
D. MOST RECENT CERTIFICATION INFORMATION
1. Name of Institution
Date of Course
City
State
Month
Day
Year
1. Name of Instructor
Number of Course Hours
Completion Date
Month
Day
Year
E. PERSONAL AFFIRMATION
Read carefully before signing
I affirm that in accordance with the requirements of 10 NYCRR 800, I have NOT been convicted of any misdemeanors or felonies.
I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar
to certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.
Do not sign this if you have any convictions.
I hearby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant.
I further understand that offering or providing false information on this document may constitute a crime under the penal law and may
subject any certification to revocation or other Department action.
Applicant’s Signature
Date
Notary Seal
Notary Signature, Affirmation, and Date
Signature of Applicant
Month
Day
Year
DOH-2183 (04/13)
NEW YORK STATE DEPARTMENT OF HEALTH
Application for New York State EMT Reciprocity
Bureau of Emergency Medical Services
A. PERSONAL DATA
1. Name
2. Date of Birth
Last
First
M.I.
Month
Day
Year
3. Mailing Address
Street
City
State
Zip
4. Social Security Number
5. Home Phone
Work Phone
(
)
(
)
B. TRAINING/CERTIFICATION – Please attach photocopies of state certifications, CPR card and military training certificates.
1. Name of Certifying Agency (state/military/registry)
2. Expiration Date
Month
Day
Year
3. Certification/Registration/License Number
4. National Registry Number (if applicable)
C. LEVEL OF TRAINING – Please attach photocopies of Certificates of Course Completion, etc.
CFR
EMT
Intermediate
AEMT
Paramedic
Please check one of the following:
I have never held any level of New York State EMS Certification.
I previously held a New York State Certification. My EMT # was:
I currently hold a New York State Certification. My EMT # is:
D. MOST RECENT CERTIFICATION INFORMATION
1. Name of Institution
Date of Course
City
State
Month
Day
Year
1. Name of Instructor
Number of Course Hours
Completion Date
Month
Day
Year
E. PERSONAL AFFIRMATION
Read carefully before signing
I affirm that in accordance with the requirements of 10 NYCRR 800, I have NOT been convicted of any misdemeanors or felonies.
I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar
to certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.
Do not sign this if you have any convictions.
I hearby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant.
I further understand that offering or providing false information on this document may constitute a crime under the penal law and may
subject any certification to revocation or other Department action.
Applicant’s Signature
Date
Notary Seal
Notary Signature, Affirmation, and Date
Signature of Applicant
Month
Day
Year
DOH-2183 (04/13)