DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7464 (Rev. 8/05)
STATE OF WISCONSIN Chapter 110, Wis. Admin. Code (608) 266-1568
EMERGENCY MEDICAL TECHNICIAN-BASIC IV TRAINING PERMIT APPLICATION
This form is authorized under s. 146.50, Wisconsin Statutes and Chapter 110, Wisconsin Administrative Code. Completion of this form is mandatory for receipt of an EMT-Basic IV Training Permit. Personally identifiable information requested on this form will only be used for licensure purposes. Provision of your social security number is required and is used by the Bureau of Local Health Support and EMS only as an identifier for licensure purposes. INSTRUCTIONS: Type or print legibly. Complete all sections of the form, sign the application, and attach a copy of both sides of your current CPR (for the professional) card and criminal history documentation, if required. Incomplete applications will not be processed
RETURN COMPLETED FORM TO YOUR INSTRUCTOR
Last Name Mailing Address City Daytime Telephone Number State Zip Code County Birth Date (Month/Day/Year) Social Security Number(required) Gender Male Wisconsin EMT License Number (required) Expiration Date ( Month/Day/Year) E-mail Address Female First Name MI Former Name(s)
Other Telephone Number
CRIMINAL HISTORY - FAILURE TO PROVIDE THIS INFORMATION WILL DELAY PROCESSING OF YOUR APPLICATION
The Fair Employment Act (sections 111.31-111.395, Wis. Stats.) prohibits employment discrimination on the basis of conviction or arrest record unless the circumstances of the conviction or arrest substantially relate to the circumstances of the particular job or licensed activity. The information requested on this form is used to determine whether a certificate/license should be granted, approved with limitations or denied. The information you provide on this form may be verified against criminal information records. Failure to report required information on this form would be considered a false statement on an application. Read carefully. All applicants must answer the following questions: Yes No Have you ever been convicted of any felony or misdemeanor offense(s) in Wisconsin or in any other state OR do you have any felony or misdemeanor offense(s) pending against you at this time? If yes, list each offense below and provide the following information for each offense: copies of the police report or criminal complaint/Information, judgment of conviction and sentence, verification of your compliance with all terms of each sentence, including chemical dependency assessments, if ordered by the court, and verification of your compliance/completion of probation or parole. Within the last 10 years, has your driver's license been suspended, revoked or withdrawn in Wisconsin or in any other state OR do you have current pending charges that may result in the suspension, revocation or withdrawal of your driver license? If yes, list each offense below and provide a current driver abstract obtained from the Department of Transportation (DOT) by calling (608) 261-2566*.
You must list all arrest(s)/conviction(s). Attach additional sheets, if necessary.
Date of Conviction
Applications will not be processed unless all required documentation is attached.
DPH 07125 (Rev. 8/05) Page 2
I certify that the above information is true and complete, that I meet the qualifications for licensure under s.146.50, Wis. Stats. and Chapter HFS 110, Wisconsin Administrative Code, I am 18 years of age or older, and am capable of performing the duties of an emergency medical technician. I further certify that the copy of the CPR card is an accurate copy of that issued to me by a certified training agency.
TRAINING CENTER AFFILIATION INFORMATION
Training Center Affiliation Training Center Number DHFS Course Approval Number
I certify that the above named applicant is affiliated with the Basic IV Training Center and course noted above.
SIGNATURE Training Center Coordinator
TRAINING COURSE MEDICAL DIRECTOR
I certify that I have accepted the above named applicant for participation in an approved EMT-Basic IV training program under my direction and endorse this application.
SIGNATURE Course Medical Director
Print or Type Course Medical Director's Name
CHECK THE FOLLOWING TO MAKE SURE YOU ARE SUBMITTING A COMPLETE APPLICATION Have you attached a copy of both sides of your current CPR (for the professional) card? If you have a criminal history, have you included all requested documents? Did you sign the application? Did you list your training center affiliation? Did your training center coordinator sign the application? Did your medical director sign the application?
*You may request a copy of your Driver License Abstract (driving record) by:
Calling the Department of Transportation (DOT), Driver License Records Section at (608) 261-2566 (automated version) or (608) 266-2353. Have your drivers license number ready. The abstract will be mailed to you and you will receive an invoice for the fee. Writing the Wisconsin Department of Transportation (DOT), Driver License Records Section, 4802 Sheboygan Avenue, Madison, WI 53702. The cost is $5.00 per record, make your check payable to the Registration Fee Trust and include your drivers license number. Only the Wisconsin Department of Transportation, Driver License Abstract will be accepted. Do not send a copy of a driving record received from a local police department or other sources.