Free None - Wisconsin


File Size: 42.0 kB
Pages: 1
Date: April 11, 2006
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS/DPH/BLHSEMS
Word Count: 512 Words, 3,241 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/dph/DPH07472A.pdf

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 7472A (Rev. 03/06)

STATE OF WISCONSIN

2006-2008 FIRST RESPONDER / EMT RENEWAL APPLICATION
Name Address City, State, Zip County of Residence License Number: First Responder Basic Intermediate Technician Intermediate Paramedic

Instructions: Enter your name, address, county, license number and level above. Answer all questions below, sign and date the form, attach a copy of your current CPR card and ACLS card, if required, and, if necessary, obtain and attach the necessary conviction information requested below. You must provide one copy of this renewal application to each service you wish to be licensed with. Once you copy this application, enter the name of the service you are affiliating with in the space below and return the application to that service. If you are not affiliated with a service provider, write "nonaffiliated" in the space below and return the entire renewal application to the Division of Public Health, Bureau of Local Health Support & EMS (BLHS&EMS), PO Box 2659, Madison, WI 53701-2659. Incomplete applications will not be processed.

Name of service you are affiliating with: ____________________________________________________________________ 1) Criminal History - Since February 1, 2004, have you been convicted of any felony or misdemeanor offense(s) not previously reported to BLHS&EMS that may be punishable by forfeiture, fine, jail, imprisonment, probation, or parole OR do you have any felony or misdemeanor offense(s) pending against you at this time? Yes No If yes, you must list each conviction or pending charge along with the date of the conviction or the current status of pending charges in the spaces below. You must also submit the relevant information for each crime or offense: (1) copy of the ticket; (2) judgment of conviction; (3) police report or criminal complaint; (4) letter from your probation/parole officer summarizing your compliance with probation/parole, if you are on supervision.

2) Driver Record - Since February 1, 2004, has your driver's license been suspended, revoked, or withdrawn or do you have current pending charges that may result in the suspension, revocation, or withdrawal of your driver license? Yes No If yes, list each offense below and submit a copy of your driver abstract from the Department of Transportation. Date of Conviction Status

List Offense(s) / Conviction(s) (Attach additional sheets, if necessary)

I certify that all information provided above is true and complete and that I meet the requirements for the renewal of my EMT license.

SIGNATURE ­ FR/EMT

Date Signed

FR/EMT: If you are affiliated with one or more services, take this completed form to your service director. DO NOT return it to the BLHS&EMS. If you are not affiliated with any service, return it to BLHS&EMS at the above address. Service Directors using EMSS: Process this renewal application only if it is fully completed and signed. Service Directors not using EMSS: Mail fully completed and signed renewal applications to Division of Public Health, BLHS&EMS, P.O. Box 2659, Madison Wisconsin 53701-2659 along with all FR/EMT renewal applications and your service provider renewal application.