DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7471 (07/03 )
STATE OF WISCONSIN Chapter 110, Wis. Admin. Code (608) 266-1568
EMERGENCY MEDICAL TECHNICIAN VERIFICATION OF LICENSURE
This form is authorized under s. 146.50, Wis. Stats ., and Chapter 110, Wis. Admin. Code. Completion of this form is mandatory for licensure as an EMT by reciprocity. Personally identifiable information requested on this form will only be used for licensure purposes. Provision of your social security number is optional and is used by the Bureau of EMS and Injury Prevention only as an identifier in the licensure database. INSTRUCTIONS: Type or print legibly. Complete Section A of this form; send a copy to all states where you have been granted a license as an EMT. SECTION A: APPLICANT INFORMATION Last Name Mailing Address City Daytime Telephone Number State Zip Code Date of Birth Other Telephone Number Social Security Number(Optional) First Name MI Former Name(s)
SECTION B: TO BE COMPLETED BY STATE LICENSING AGENCY The above-named individual has applied for a Wisconsin EMT license based upon reciprocity from your state. Complete Section B of this form and forward to the Wisconsin Department of Health and Family Service. State Verifying License License Number
This applicant is/was certified/licensed/registered in your state as: First Responder EMT-Basic EMT-Intermediate (1985 curriculum) EMT-Paramedic (1986 curriculum) Other: Date of last DOT-approved refresher training: Yes No or or EMT-Intermediate (1999 curriculum) EMT-Paramedic (1999 curriculum)
Has this applicant's EMT license ever been denied, reprimanded, limited, suspended or revoked?
If yes, please provide a copy of the disciplinary action. Yes No Is there any reason this applicant should not be licensed in Wisconsin?
If yes, please explain:
SECTION C: STATE LICENSING AGENCY CERTIFICATION Print name of person completing this form Title
Mail or FAX completed form to:
DEPARTMENT OF HEALTH AND FAMILY SERVICES BUREAU OF EMS AND INJURY PREVENTION LICENSING MANAGER PO BOX 2659 MADISON WI 53701-2659 FAX: 608-261-6392