Free EMT-Basic Training Permit Application, DPH 7128 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7128 (Rev. 7/05)

STATE OF WISCONSIN Chapter 110, Wis. Admin. Code (608) 266-1568

EMERGENCY MEDICAL TECHNICIAN-BASIC TRAINING PERMIT APPLICATION
This form is authorized under s. 146.50, Wisconsin Statutes and Chapter 110, Wisconsin Administrative Code. Completion of this form is required for receipt of an EMT-Basic Training Permit. Personally identifiable information, including social security number, is required and used by the Bureau of Local Health Support and Emergency Medical Services as an identifier for licensing purposes only. 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 healthcare professional) card and criminal history documentation, if required. Incomplete applications will not be processed. RETURN COMPLETED FORM TO: DIVISION OF PUBLIC HEALTH BUREAU OF LOCAL HEALTH SUPPORT AND EMS PO BOX 2659 MADISON, WI 53701-2659 First Name MI Former Name(s)

APPLICANT INFORMATION
Last Name Mailing Address City Daytime Telephone Number WI EMT Number (If applicable) State Zip Code County Birth Date (MM/DD/YYYY) E-mail Address Social Security Number (Required) Gender Male Expiration Date ( MM/DD/YYYY) Female

Alternate 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*. Date of Conviction Status

Yes

No

You must list all arrest/conviction(s). Attach additional sheets, if necessary.

Applications will not be processed unless all required documentation is attached.

DPH 07128 (Rev. 7/05)

Page 2 Training Center Name and Location Completion Date

TRAINING INFORMATION
Training Course Completed Cardiopulmonary Resuscitation for the Professional Rescuer (attach copy of both sides of card) AND DOT First Responder (attach copy of course completion certificate) - OR Completion of the first 46 hours of EMT-Basic course and current CPR verified by instructor's signature American Heart Association (AHA) Health Care Provider Course American Red Cross (ARC) for the Professional Rescuer Other CPR CPR Expiration Date

Instructor's Signature

Date

APPLICANT CERTIFICATION
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 17 years of age or older, and am capable of performing the duties of an emergency medical technician. I further certify that (if attached) the copy of the CPR card and the First Responder Course completion certificate are accurate copies of those issued to me by a certified training agency.

SIGNATURE ­ Applicant

Date Signed

AMBULANCE SERVICE AFFILIATION INFORMATION (service affiliation is required for training permit)
Ambulance Service Provider Affiliation Provider License Number

I certify that the above named applicant is affiliated with the ambulance service provider noted above.

SIGNATURE ­ Ambulance Service Provider (responsible party)

Date Signed

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? Have you attached a copy of your First Responder Course completion certificate? OR Did your course instructor sign the application? If you have a criminal history, have you included all requested documents? Did you sign the application? Did your ambulance service provider 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.