Doh 3312 Form PDF Details

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QuestionAnswer
Form NameDoh 3312 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesverification nys ems, 3312 form, 3312 ems, 3312

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH

Verification of Membership

Bureau of Emergency Medical Services

in a NYS EMS Agency

 

 

Please print legibly in capital letters or type. Put one letter or number in each box.

This form must be completed and returned to the Course Sponsor prior to the completion of the course.

Course Number

( Please retain this number for future reference)

Check if this application is for:

Original Certification

Recertification ( I f you are recertifying you must include your NYS EMS I .D. Number)

EMS I dentification Number ( I f you have one)

Only w rite your NYS EMS number in t his space

Applicant’s Last Name

Applicant’s First Name and M.I

I f you belong to an EMS agency, please indicate the agency code in the box( es) below .

 

Primary EMS Agency

 

Secondary EMS Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Agency Name

Primary Agency Captain, Chief, or other agency official signing the affirmation on this form

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NYS EMS I dentification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name and M.I .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number ( I f you have one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Official’s Agency Tit le

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Affirmation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Read Carefully Before Signing

I , as an official representative of the primary NYS EMS agency listed on this form, affirm that the applicant named on this form is a member of the

primary NYS EMS service. I further understand that offering or providing false information on this document may constitute a crime under the penal law and may subject any certification to revocation or other Department action.

I , as the applicant, hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant . I further understand that offering or providing false information on this document may constitute a crime under the penal law and may subject any certification to revocation or other Department action.

( Agency Official’s Signature)

( Date)

( Applicant’s Signature)

( Date)

DOH- 3312 ( 5/ 07)

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In an effort to complete this PDF form, make sure that you provide the required details in each and every field:

1. The doh agency form necessitates particular information to be typed in. Be sure that the following blank fields are complete:

ny ems agency writing process clarified (portion 1)

2. Immediately after this section is completed, proceed to type in the relevant details in all these: Last Name, First Name and MI, Officials Agency Title, NYS EMS I dentification, Number I f you have one, Personal Affirmation Read, Agency Officials Signature, Date, and Date.

NYS EMS I dentification, First Name and MI, and Date of ny ems agency

As for NYS EMS I dentification and First Name and MI, be sure that you get them right in this current part. Both of these are the most important ones in the PDF.

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