"Emergency Medical Services (EMS) Systems License Fee Waiver Application" - Illinois

Emergency Medical Services (EMS) Systems License Fee Waiver Application is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

Form Details:

  • Released on January 1, 2016;
  • The latest edition currently provided by the Illinois Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Emergency Medical Services (EMS) Systems License Fee Waiver Application" - Illinois

Download PDF

Fill PDF online

Rate (4.6 / 5) 24 votes
Page background image
State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems
License Fee Waiver Application
The License Fee Waiver Application must be completed before further processing will be considered.
Under Section 3.50(d)(9) of the Emergency Medical Services Systems Act, an emergency medical technician (EMT) who
exclusively serves as a volunteer for units of local government or a not-for-profit organization that serves a service area with a
population base of less than 5,000 may submit an application to the Department for waiver of license fees on a form prescribed
by the Department.
Under Section 3.60(b)(7) of the Emergency Medical Services Systems Act, a first responder who exclusively serves as a
volunteer for units of local government or a not-for-profit organization that serves a service area with a population base of less
than 5,000 may submit an application to the Department for a waiver of these fees on a form prescribed by the Department.
Illinois State Police
Illinois National Guard
Volunteer - Less Than 5,000 Population
Name ___________________________________________________________
EMT
First Responder
Address___________________________________________________ Current EMS License Number________________
City ________________________________________ State __________________________ ZIP Code ______________
Date of Birth _______________________________________________ Social Security Number _____________________
Driver’s License Number _____________________________________ Phone Number ___________________________
E-mail Address _____________________________________________ EMS System _____________________________
Personal History Statement:
Have you ever been convicted or plead guilty of any felony offense?
Yes
No
If yes, provide a complete and signed explanation, in your own words, of the nature of the offense and the conviction(s). An
additional fee and authorization for release of information must be submitted to IDPH to obtain a criminal history report from the
Illinois State Police or another applicable law enforcement agency. An authorization for release of information will be required.
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 above information and all supporting documents submitted by me
in connection with this request and, to the best of my knowledge and belief, they are correct and complete.
______________________________________________________________________
__________________________
Applicant Signature
Date
I attest that the above named applicant meets the requirements of the Emergency Medical Services Systems Act for this fee waiver request.
______________________________________________________________________
__________________________
EMS System Coordinator
Date
License Fee Waiver processed on: _______________
by _______________________________________
IOCI 16-313
1/16
Printed by Authority of the State of Illinois
State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems
License Fee Waiver Application
The License Fee Waiver Application must be completed before further processing will be considered.
Under Section 3.50(d)(9) of the Emergency Medical Services Systems Act, an emergency medical technician (EMT) who
exclusively serves as a volunteer for units of local government or a not-for-profit organization that serves a service area with a
population base of less than 5,000 may submit an application to the Department for waiver of license fees on a form prescribed
by the Department.
Under Section 3.60(b)(7) of the Emergency Medical Services Systems Act, a first responder who exclusively serves as a
volunteer for units of local government or a not-for-profit organization that serves a service area with a population base of less
than 5,000 may submit an application to the Department for a waiver of these fees on a form prescribed by the Department.
Illinois State Police
Illinois National Guard
Volunteer - Less Than 5,000 Population
Name ___________________________________________________________
EMT
First Responder
Address___________________________________________________ Current EMS License Number________________
City ________________________________________ State __________________________ ZIP Code ______________
Date of Birth _______________________________________________ Social Security Number _____________________
Driver’s License Number _____________________________________ Phone Number ___________________________
E-mail Address _____________________________________________ EMS System _____________________________
Personal History Statement:
Have you ever been convicted or plead guilty of any felony offense?
Yes
No
If yes, provide a complete and signed explanation, in your own words, of the nature of the offense and the conviction(s). An
additional fee and authorization for release of information must be submitted to IDPH to obtain a criminal history report from the
Illinois State Police or another applicable law enforcement agency. An authorization for release of information will be required.
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 above information and all supporting documents submitted by me
in connection with this request and, to the best of my knowledge and belief, they are correct and complete.
______________________________________________________________________
__________________________
Applicant Signature
Date
I attest that the above named applicant meets the requirements of the Emergency Medical Services Systems Act for this fee waiver request.
______________________________________________________________________
__________________________
EMS System Coordinator
Date
License Fee Waiver processed on: _______________
by _______________________________________
IOCI 16-313
1/16
Printed by Authority of the State of Illinois