Free None - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7477 (Rev. 02/06)

STATE OF WISCONSIN Chapter 110, 111, 112, 113, Wis. Admin. Code (608) 266-1568

FIRST RESPONDER/EMERGENCY MEDICAL TECHNICIAN CERTIFICATE/LICENSE APPLICATION
This form is authorized under s. 146.50, Wis. Stats. and Chapters 110, 111, 112 and 113, Wis. Admin. Code. Completion of this form is mandatory for certification/licensure. Personally identifiable information requested on this form will only be used for certification/licensure purposes. Provision of your social security number is required and is used by the Bureau of Local Health Support & EMS only as an identifier in the database.

INSTRUCTIONS: Type or print legibly. Complete all sections of this application, sign it and attach a copy of both sides of your current CPR (for the healthcare professional) card and your ACLS card, if required. All applicants must attach a copy of a current National Registry card. Incomplete applications will be returned without action. Return this completed application to the service director to obtain affiliation with a service. If you are applying for No Service Affiliation, return the completed application to the following address: DIVISION OF PUBLIC HEALTH RETURN COMPLETED FORM TO: BUREAU OF LOCAL HEALTH SUPPORT & EMS P.O. BOX 2659 MADISON, WI 53701-2659

Indicate the purpose of this application:
Original licensure ­ trained in Wisconsin Original licensure by reciprocity ­ trained out of state Reinstate expired license ­ Expiration date: Change WI license level Intermediate Technician Intermediate Paramedic

License level requested:
Medical First Responder Basic

Service Provider Affiliation:

If none, check here
Provider License Number

Name of Service Provider, required if affiliated

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

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 provide requested information on this form will be considered a false statement on an application. 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. Yes No 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*. List Arrest(s)/Conviction(s) - Category of offenses listed must match the above questions. Date of Conviction Status

Attach additional sheets, if necessary. Applications will not be processed unless all required documentation is attached. OVER

DPH 7477 (05/04) Page 2 Have you ever been licensed as a First Responder or EMT in any other state? If yes, complete a "Verification of License" form available at

www.dhfs.wisconsin.gov/ems or by calling (608) 266-1568.
Yes No If yes, list State(s) and level(s):

Have you ever had a professional license denied, limited, suspended, or revoked in Wisconsin or in any other state? Yes No If yes, attach a written explanation and a copy of the order.

Have you ever been discharged from a branch of the US armed forces with a discharge other than honorable? Yes No List type and date of discharge: If yes, you must attach a copy of your discharge papers (DD214) that indicates your separation status and a written explanation.

TRAINING INFORMATION ­ If trained outside Wisconsin, you must submit a copy of your course completion certificate(s).
Level of Initial Training Completed Training Center Name and Location Completion 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, 111, 112, 113, Wis. Admin. Code, at the level indicated on page 1 of this application. I certify that I am 18 years of age or older, and am capable of performing the duties of a first responder/emergency medical technician. I certify that the copy of the National Registry wallet card attached to this form is a true and accurate copy of that issued to me by the National Registry. I further certify that the copy of the CPR card and ACLS card, if required, is an accurate copy of that issued to me by a certified training agency.

SIGNATURE - Applicant

Date Signed

SERVICE AFFILIATION CERTIFICATION
I certify that the above named applicant is affiliated with the service provider noted above at the FR/EMT level indicated on page 1.

SIGNATURE - Service Provider (responsible party)

Date Signed

SERVICE MEDICAL DIRECTOR CERTIFICATION
I certify that I accept the above named applicant for participation in an approved FR/EMT program under my medical direction and endorse this application at the level indicated on page 1 of this application.

SIGNATURE - Medical Director

Date Signed

Print or Type 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 healthcare professional) card and ACLS card, if applicable? Have you attached a copy of your current National Registry wallet card for the level for which you are applying? If you have a criminal history or reportable driving record, have you included all required documents? Have you signed the application? If you are affiliating with a service, has the service director and medical director signed the application? *Only the Wisconsin Department of Transportation, Driver License Abstract will be accepted. If your offense(s) occurred while a resident of another state, contact that state for a Driver License Abstract. Do not send a copy of a driving record received from a local police department or other sources.