NORTHERN CALIFORNIA EMS, INC. 930 Executive Way, Suite 150, Redding, CA Phone: (530) Fax: (530)

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1 NORTHERN CALIFORNIA EMS, INC. 930 Executive Way, Suite 150, Redding, CA Phone: (530) Fax: (530) EMT Application Check One: INITIAL CERTIFICATION RENEWAL CERTIFICATION Please write clearly and answer all questions or your application may be rejected. Need It Fast? Apply Online at: Name: Mailing Address: SSN: DOB: City: State: Zip Code: County: DL#: State: Home #: Work #: Cell #: EMT Certification #: Effective Date: Expiration Date: Address: Currently employed as an EMT?: Yes No If yes, Provider s Name: All information on this application is subject to verification. Applications will not be processed until ALL REQUIRED ITEMS are received. Be sure to copy the front and back of all cards! INITIAL CERTIFICATION REQUIREMENTS Check-off Copy of current Government issued photo ID Copy of current CPR Card (AHA or equivalent) Copy of processed Nor-Cal EMS DOJ Live Scan Service Form Copy of EMT Course Completion Certificate or copy of current State EMT Card Copy of NREMT Card Pay Application Fee RENEWAL CERTIFICATION REQUIREMENTS Check-off Copy of current Government issued photo ID Copy of current CPR Card (AHA or equivalent) Copy of current State EMT Card Copy of CA EMT Skills Competency Verification Form ( ) Copy of Continuing Education Log ( ) to include 24 hours of CEs or EMT Refresher Course Certificate of Completion. Lapse of 6 months or longer - see Policy for additional CE/Educational requirements ICS (FEMA) Training/Refresher Course Date (See CE Log) Pay Application Fee 1. Have you ever had a certification, accreditation, or professional healing arts license denied, suspended, revoked or placed on probation, or are you under investigation at this time? If yes, you must attach a detailed statement with this application that describes the action, any corrective action, and/or remediation as a result of the action. YES NO 2. 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 ? If yes, you must attach a detailed statement describing the crime(s), date, location, court, sentence served, and parole if any. You must also attach any applicable court documents and police reports. YES NO 3. Are there any criminal charge(s) currently pending against you? If yes, you must attach a detailed statement describing the charge(s), date, location, and court, if any. You must also attach any applicable court documents and police reports. YES NO 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 EMT certification in the State of California. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as an EMT in the State of California. SIGNATURE OF APPLICANT: See Page 2 for Payment Information DATE:

2 EMT INITIAL CERTIFICATION PAYMENT INFORMATION: (CHECK ONE) PAYING BY CHECK OR MONEY ORDER $ NOR-CAL EMS CERTIFICATION FEE ( INCLUDES STATE FEE) PAYING BY CREDIT CARD $ NOR-CAL EMS CERTIFICATION FEE (INCLUDES STATE FEE + $2.00 PROCESSING FEE) COMPLETE PAYMENT INFORMATION BELOW EMT RENEWAL CERTIFICATION PAYMENT INFORMATION (CHECK ONE) IS YOUR CERTIFICATION: CURRENT PAYING BY CHECK OR MONEY ORDER PAYING BY CREDIT CARD (COMPLETE INFO BELOW) $65.00 NOR-CAL EMS CERTIFICATION FEE $67.00 NOR-CAL EMS CERTIFICATION FEE (INCLUDES STATE FEE) (INCLUDES STATE FEE + $2.00 PROCESSING FEE) EXPIRED CERTIFICATION (LESS THAN 12 MONTHS) PAYING BY CHECK OR MONEY ORDER PAYING BY CREDIT CARD (COMPLETE INFO BELOW) $82.00 NOR-CAL EMS CERTIFICATION FEE $84.00 NOR-CAL EMS CERTIFICATION FEE (INCLUDES STATE FEES) (INCLUDES STATE FEE + $2.00 PROCESSING FEE) CONTACT NOR-CAL EMS IF YOU ARE EXPIRED GREATER THAN ONE YEAR OR ARE TRANSFERRING FROM ANOTHER LEMSA INCLUDE ONE CHECK OR MONEY ORDER MADE PAYABLE TO NOR CAL EMS OR IF PAYING BY CREDIT CARD COMPLETE THE FOLLOWING INFORMATION: CARDHOLDERS NAME CARD NUMBER VISA OR MC 3 DIGIT CVV CODE EXPIRES (MONTH / YR) CARDHOLDERS SIGNATURE CHARGE AMOUNT BILLING ADDRESS CITY STATE ZIP PHONE NUMBER ADDRESS FOR MORE INFORMATION OR TO APPLY ONLINE VISIT OUR WEBSITE AT: OR SEND COMPLETED APPLICATION AND ALL DOCUMENTATION TO: NOR-CAL EMS CERTIFICATION DEPARTMENT 930 EXECUTIVE WAY, SUITE 150 REDDING, CA ALLOW TWO WEEKS PROCESSING TIME. All fees are non-refundable; non transferrable and subject to change A $35.00 CHARGE WILL BE IMPOSED ON ALL CHECKS RETURNED FOR NON-SUFFICIENT FUNDS (NSF) NOR-CAL EMS USE FEES PAID: DATE RECEIVED: CHECK: DATE PROCESSED: CASH: EFFECTIVE DATE: CREDIT CARD: EXPIRATION DATE: Page 2

3 Nor-Cal EMS Policy & Procedure Manual BLS CERTIFICATIONS EMT Skills Competency Verification Form State of California EMT Skills Competency Verification Form EMSA SCV (01/17) See attached for instructions for completion This section is to be filled out by the EMT whose skills are being verified: I certify that I have performed the below listed skills before an approved verifier and have been found competent to perform these skills in the field. Name as shown on California EMT Certificate EMT Certificate Number Signature This section is to be filled out by an approved Verifier (see instructions for information on approved Verifiers). By filling out this section the Verifier certifies that they have, through direct observation, verified that the above EMT is competent in the skills below. Skill Verified Verifier's Information 1. Trauma Assessment 2. Medical Assessment 3. Bag-Valve-Mask Ventilation 4. Oxygen Administration 5. Cardiac Arrest Management w/ AED 6. Hemorrhage Control & Shock Management 7. Spinal Motion Restriction- Supine & Seated 8. Penetrating Chest Injury 9. Epinephrine & Naloxone Administration Not Applicable until 7/1/ Childbirth & Neonatal Resuscitation Originated: January 1, 2006 Last Revision: July 1, 2017 Page: 1 of 2

4 BLS CERTIFICATIONS EMT Skills Competency Verification Form # State of California EMT Skills Competency Verification Form EMSA SCV (01/17) INSTRUCTIONS FOR COMPLETION OF EMT SKILLS COMPETENCY VERIFICATION FORM 1. A completed EMT Skills Verification Form (EMSA-SCV 01/17) is required for those individuals who are either renewing or reinstating their EMT certification. This verification form must accompany the application. 2. Verification of skills competency shall be accepted as valid to apply for EMT renewal or reinstatement for a maximum of two (2) years from the date of skill verification. 3. The EMT that is being skills tested shall provide their complete name as shown on their California EMT certification, the EMT certificate number and signature in the spaces provided. 4. Verification of Competency Once skills competency has been demonstrated by direct observation of an actual or simulated patient contact, i.e. skills station, the individual verifying competency shall: a. Sign the EMT Skills Competency Verification Form for that skill. b. Print their name on the EMT Skills Competency Verification Form for that skill. c. Enter the date that the individual demonstrated the competency of the skill. d. Provide the name of the organization that has approved them to verify skills. e. Provide their certification or license type and number. 5. In order to be an approved skills verifier you must meet the following qualifications: a. Be currently licensed or certified as an EMT, AEMT, Paramedic, Registered Nurse, Physician Assistant, or Physician, and b. Be approved to verify by: i. EMT training program, or ii. AEMT training program, or iii. Paramedic training program, or iv. Continuing education providers, or v. EMS service provider (including but limited to public safety agencies, private ambulance providers, and other EMS providers). Originated: January 1, 2006 Last Revision: July 1, 2017 Page: 2 of 2

5 AUTHORITY: Nor-Cal EMS Policy & Procedure Manual BLS CERTIFICATIONS Emergency Medical Technician Continuing Education Log Health and Safety Code Division 2.5, California Code of Regulations, Title 22, Division 9 POLICY: C.E.s and courses SHALL be obtained by an approved Pre-hospital Continuing Education Provider. These records are subject to audit by Nor-Cal EMS. You are required to maintain your original continuing education records for four (4) years. ICS Initial/Refresher Training Date: (EMT Policy # ) (An interactive web-based course is available at training.fema.gov IS-100B) DATE COURSE TITLE CE PROVIDER NAME and NUMBER CE HOURS Total number of hours If you need additional space, please attach a separate sheet of paper. Print Name: Certification #: Signature: Date: / / Originated: July 1, 2006 Last Revision: July 1, 2017 Page: 1 of 1

6 . Sex Live Requesting STATE OF CALIFORNIA ) BCIA8O16 / \ (avg 04/2001, rev 01/2011) DEPARTMENT OF JUSTICE REQUEST FOR LIVE SCAN SERVICE Applicant Submission A0536 ORI (Code aasigned by DO]) EMT - Nor Cal EMS Type of License/Certification/Permit OR Working Title (Maximum 30 characters - Contributing Agency Information: Emerg Med Tech Lic/Cert Authorized Applicant Type If assigned by DO], use exact title assigned) Emergency Medical Services Authority Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ) Gold Center Drive, Suite 400 Shona Merl Street Address or P.O. Box Contact Name (mandatory for all school submissions) Rancho Cordova CA (916) City T ZIP Code Contact Telephone Number Applicant Information: Last Name First Name Middle Initial ath Other Name (AKA or Alias) Last First Suffix Date of Birth Male Female Drivers License Number Billing Height Weight Eye Color Hair Color Number APPLICANT MUST PAY (Agency Eilling Number) Misc. Place of Birth (State or Country) Social Security Number Number (Other identification Number) Home Address Street Address or P.O. Box City State ZIP Code Your Number: Level of Service: DOJ FBI OCA Number (Agency Identifying Number) If re-submission, list original AT! number: (Must provide proof of rejection) Original All Number Employer (Additional response for agencies specified by statute): EMSA Employer Name Mail Code (five digit code assigned by DOJ) Gold Center Drive, Suite 400 Street Address or P.O. Box Rancho Cordova CA (916) City State ZIP Code Telephone Number (optional) Live Scan Transaction Completed By: Name of Operator Date Transmitting Agency LSID ATI Number Amount Collected/Billed ORIGINAL - Scan Operator SECOND COPY - Apphcant THIRD COPY (if needed) - Agency