NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION

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1 PLEASE PRINT OR TYPE APPLICATIONS MUST HAVE ORIGINAL SIGNATURES NM EMS License # * SSN of Birth Last Name First Name Middle Initial Gender: Male Female Has your name changed since your last renewal? Yes No If yes, previous name White/Caucasion Asian NEW MEXICO EMS PROVIDER 2017 LICENSURE RENEWAL APPLICATION African American/Black Pacific Islander/ Native Hawaiian (Include a copy of legal documentation) Hispanic American Indian/ Alaska Native * The submission of a social security number is required under the child support enforcement provisions of the Social Security Act, 42 USCA Section 666. RENEWAL LEVEL and STATUS (CHECK ALL THAT APPLY) Emergency Medical Dispatcher EMS First Responder EMT-Basic EMD - Instructor EMT-Intermediate EMT-Paramedic Active Inactive Mailing Address City County Home Phone Name of Employer Working in EMS Basis CURRENT APPLICANT ADDRESS State Address Cell Phone PRIMARY EMS EMPLOYMENT INFORMATION Work Setting per week CAREER DEVELOPMENT Zip Code Work Phone EMS Job Liability Insurance Education Languages Spoken 5 Year Plan We DO NOT accept cash or credit card payments Make payable to the EMS For Applicant/ Agency For EMS Use Only: Check / P.O. / Money Order # Amt $ Received: Initials:

2 MEDICAL DIRECTION - COMPLETION OF THIS SECTION IS MANDATORY (1)I,, hereby certify that as a Licensed EMD, EMS First Responder or EMT-Basic, I am not performing any skills or other treatment modalities requiring medical direction as explained in the New Mexico Scopes of Practice. INITIAL HERE: Or, if you are an EMT-I or EMT-P not currently providing advanced level care through an EMS agency and/or do not have a Medical Director; you may for good cause, petition the EMS in writing to be placed on INACTIVE status. OR (2) If you are an EMD dispatching for an agency providing Emergency Medical Dispatch pre-arrival instructions, or an EMS FR/EMT-B/EMT-I/EMT- P working/volunteering for an EMS agency providing any skill(s) or other treatment modality requiring medical direction per the New Mexico Scopes of Practice, you must have your medical director certify your competency by signing below. As Medical Director for (print name), I hereby certify that the applicant is competent in all skills and other treatment modalities requiring medical direction as explained in the New Mexico Scopes of Practice. Medical Director Name License # Medical Director (print name) (signature) (IF YOU ANSWER YES TO ANY QUESTION BELOW, PLEASE ATTACH SUPPORTING DOCUMENTATION) Since your last license renewal, have you been convicted of any misdemeanor or felony under the laws of any state, the United States,US territories, military, or foreign country? (Please consult with your attorney or contact the EMS if you have questions regarding the disclosure[s] required). Yes No Are you presently addicted to alcohol or any controlled substance? Yes No At any time has any certification/licensure action been taken against you in any country, state or municipality including denial, suspension or revocation? If yes, please attach an explanation and documentation. Yes No Do you currently have pending court charges, or have you had court ordered interlock devices installed since your last renewal? Yes No * Fingerprint Registration ID # Transaction Control Number Affirmation I hereby affirm that all documented continuing education listed and all the information provided in this application is true and correct. It is understood that false statements or false documents may be sufficient cause for denial, suspension, or revocation of licensure by the NM EMS. It is also understood the the NM EMS may conduct an audit of my submitted CE documentation at any time. Original Signatures ONLY. No faxes or s accepted Applicant Signature Submit Complete Renewal Application to: 1301 Siler Rd. Bldg. F Santa Fe, NM 87507

3 Topic Course Sponsor Synchronous or Preparatory Airway, Resp. & Vent. Patient Assessment Medical

4 Topic Course Sponsor Synchronous or Medical (Cont.) Special Considerations Trauma

5 Topic Course Sponsor Synchronous or Trauma (Cont.) Operations CPR Certification ACLS Certification Attach a copy of the front and back of your provider card or certification. Attach a copy of the front and back of your provider card or certification. I hereby affirm that all the documented continuing education listed is true and correct. I understand that any false statement(s) or documentation may be sufficient cause for suspension/revocation of licensure by the EMS. I understand that the NM EMS may conduct an audit of any submitted continuing Education documentation. Applicant Signature: :