Fill a Valid C 08 B Georgia Template

APPLICATION – PRINT IN INK OR TYPE

* The non-refundable fee must accompany this application. Payment must be in the form of Money Order, Business Check

or Cashier's Check Only. MAKE ALL FEES PAYABLE TO "GEORGIA DEPARTMENT OF PUBLIC HEALTH"

PERSONAL INFORMATION

Phone (______) _______ - __________ E-Mail ____________________________________________________

CERTIFICATION REQUIREMENTS - Applicant shall provide all listed information and/or documents

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

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BACKGROUND DISCLOSURE

► Have you ever been arrested and/or convicted of any National, Federal, State or Local felony and/or

If you answered yes to either of the above questions, attach a detailed written statement, signed and dated, describing the crime(s), date, location, court, sentence served, and parole, if any. Attach copies of all related records, court documents and police reports.

► Have you ever been denied the privilege of taking an examination given by any state licensing board

or been denied a certificate or license?__ Yes __ No ► Have you ever resigned from any employment after a complaint or peer review action has been initiated

► Have you ever had a certification, accreditation or professional healing arts license suspended, revoked

or placed on probation; and/or are you currently under investigation?__ Yes __ No

If you answered yes, attach a detailed written statement, signed and dated, describing the event, investigation, action, any corrective action, and/or remediation as a result of the action.

All applications are processed within 5-7 business days from the date received. Congratulations! Your willingness to serve Georgia’s citizens as an EMS professional is appreciated!

I acknowledge and state that I have read and answered all questions in compliance with this application. I acknowledge that it is my responsibility to read and become familiar with the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services 111-9-2.

I further state that by filing this application for a license in the State of Georgia, I hereby authorize and consent to have an investigation made as to my moral character, professional reputation and fitness for practice as an EMS provider. I agree to give any further information which may be required in reference to my past record. I understand that I will not receive a copy of the report or know its contents and I further understand that the content of the investigative report will be privileged, unless determined otherwise by the Board or Court Order.

I hereby release, discharge, and exonerate the Georgia Department of Public Health, its agents, representatives, and any person so furnishing information, from any and all liability of every nature and kind arise out of the furnishing or inspection of such documents, records or other information or the investigation made by the Georgia Department of Public Health. I authorize the Georgia Department of Public Health to release information, material, documents, orders of the like relating to me or to this application to any other agency of the State of Georgia, the licensing agency of any other State or Territory of the United States or Province of Canada, a law enforcement agency, a hospital, or other agencies determined by the Board.

This is to certify that the foregoing information is true and correct to the best of my knowledge. I understand that any person who shall give false or forged evidence of any kind to the Board may be prosecuted to the fullest extent allowed by law.

Being duly sworn, says that he/she is the person who executed this application for licensure as an EMS provider in the State of Georgia; and that all the statements herein contained are true in every respect and that the attached photo is a true photo of applicant.

Notary: DO NOT notarize this section unless a passport photograph is attached.

FORM C-08-B: OUT-OF-STATE APPLICATION FOR LICENSE

This form is used to verify the good standing of EMT or paramedic license or certification applicants who are licensed or certified by another state. Please note that you must submit a separate form for each license and/or certification you hold. Your application cannot be processed without this form.

PART I: Completed by Applicant

Legal Name: _______________________________________________ SSN: ______ - ______ - __________

Current Address: ______________________________________________________________________________

______________________________________________________________________________

►I am requesting Georgia license based on the following current license(s) or certification(s):

___ in the state of __________________ AND by the National Registry of EMTs

Current certification(s) or license(s) in another state or issued by the National Registry of EMTs:

PART II: Completed by the State Certifying Agency

Please assist by verifying that this individual is currently certified and in good standing according to your certification policies.

A. Is the above-referenced cited certificates(s) or license(s) deemed current and valid according to your

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Title: _________________________

State: _________________________

Date: _________________________