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.
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.
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.