CCEMS Application - DPH.EpiSuite.Web.Application

Applicant information

First Name

M.I.

Last Name

Information Changed

Drivers License

Date of Birth

SSN

Sex

Race

Email Address

Phone Number

Address

Apt No

City

State

Zip Code

Certification Requested

Level of Certification

Employer

Current Expiration Date

State License Number

Local Certification Number

Have you ever been convicted of any felony or misdemeanor offense in California or in any other state or place, including entering a plea of nolo contendere or no contest and, including any conviction which has been expunged (set aside) or records sealed under Penal Code Section 1203.4?

Are there any criminal charges currently pending against you?

If you answered yes to either of these questions, you must attach a detailed statement describing the crime(s), date, location, count, sentence served, and parole if any. You must also attach any applicable court documents and police reports.

Check here if previously disclosed and on file with Central California EMS Agency.

Have you ever had a certification, accreditation or professional healing arts license denied, suspended, revoked or place on probation, or are under investigation at this time?

If yes, you must enclose with this application a written explanation that describes the action, any corrective action, any remediation as a result of the action, and the name and address of the certifying or licensing authority involved.

Check here if previously disclosed and on file with Central California EMS Agency.

I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to certification or local accreditation by the Central California Emergency Medical Services Agency. I understand all information on this application is subject to verification, and I hereby give my express permission for CCEMSA to conduct a background investigation, or to provide appropriate information related to my role and function as a certified or locally accredited individual to the State of California EMS Authority, or other local EMS Agency.

IMPORTANT: Please upload all relevant documents BEFORE clicking Save.
By clicking the Save button, I acknowledge that I have read and agree to the statement above.

Cancel

Application for Certification/Accreditation or Re-Certification/Re-Accreditation

Instructions:

All applicants are required to complete the form below.

THE FORM MUST BE FULLY COMPLETED TO PREVENT ANY DELAYS.

Once completed, click Save.

Applicant information

IMPORTANT: Please upload all relevant documents BEFORE clicking Save.
By clicking the Save button, I acknowledge that I have read and agree to the statement above.

Applicant Documents

Application for Certification/Accreditation or Re-Certification/Re-Accreditation

Instructions: All applicants are required to complete the form below. THE FORM MUST BE FULLY COMPLETED TO PREVENT ANY DELAYS. Once completed, click Save.

Applicant information

IMPORTANT: Please upload all relevant documents BEFORE clicking Save. By clicking the Save button, I acknowledge that I have read and agree to the statement above.

Applicant Documents

Instructions:

All applicants are required to complete the form below.

THE FORM MUST BE FULLY COMPLETED TO PREVENT ANY DELAYS.

Once completed, click Save.

IMPORTANT: Please upload all relevant documents BEFORE clicking Save.
By clicking the Save button, I acknowledge that I have read and agree to the statement above.