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NEW YORK STATE DEPARTMENT OF HEALTH	Application for Emergency Medical
Bureau of Emergency Medical Services	Services Certification

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

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 this space

Last Name

First Name and M.I .

Check this box if your name as stated above has changed or is spelled differently than on your current EMS card. Enter on the line below , your name as it appears on your current EMS card.

( Please Print Clearly or Type)

Address

Number and Street ( Skip one space betw een number and street)

City

State

Zip Code

County

Date of Birth

Month

Day

Year

Social Security

Sex

On Teaching Faculty

( Enter M or F)

YES

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

Primary EMS Agency

Secondary EMS Agency

Day Telephone

Practical Skills Exam Date

NYS Written Exam Date

Month

Day

Year

Month

Day

Year

Personal Affirmation

Read Carefully Before Signing

Iaffirm that in accordance with the requirements of 10 NYCRR Part 800, I have NOT been convicted of any misdemeanors or felonies. I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.

Do not sign this if you have any convictions

Ihereby 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.

( Applicant Signature)

( Date)

DOH- 65 ( 1/ 2009) page 1 of 2

1 .	Fill out this form legibly and accurately. Failure to do so can cause delay in your being allow ed to test or
	inaccurate information on your certificate.
2 .	COURSE NUMBER: Fill in the course number. I t is provided to the I nstructor/ Coordinator on the course
	approval slip.
3 .	Check ORI GI NAL CERTI FI CATI ON Box if:

A.This is the first time you have enrolled in an Emergency Medical Services certification course or,

B.You are applying for an advanced EMT certification in a category in w hich you are not currently certified.

4 .	Check RECERTI FI CATI ON COURSE box if you are applying for recertification, basic or advanced.
5 .	EMS I DENTI FI CATI ON NUMBER: Enter the six ( 6) numbers of your EMS identification number. I f your number
	is less than six digits, add zeros in front to complete the number of six digits ( Example: EMS No. 94 w ould be
	000094) . Only enter your New York State EMS number.
6 .	NAME: Enter your last name. I f you use a notation after your name ( such as Jr.) enter it after your last name.
	I n the next set of boxes, enter your first name in full, leave a space, and enter your middle initial. I f you do
	not have room to enter your name in full, please abbreviate.
7 .	I f you EMS certificate show s an incorrect name or you have changed your name since it w as issued, check the
	box and w rite in the name that is on your current certificate.
8 .	ADDRESS: Write your mailing address. The first line is for your number and street, or post office box. Leave a
	space betw een w ords for box numbers. The second line is the city, state and the third line is for zip codeand
	county w here you w ill be receiving your mail.
9 .	COUNTY: Enter the county in w hich you live. NOTE: Manhattan is New York ( NEWY) - Staten I sland is
	Richmond ( RI CH) - Brooklyn is Kings ( KI NG) - St . Law rence is STLA - Out of State is OUTS
10 .	DATE OF BI RTH: Enter your date of birth putting tw o digits each in the month, day and year boxes. Alw ays
	use a "0" to complete 2 digits ( i.e. January is "01")
11 .	SOCI AL SECURI TY: Please fill in the last 4 digits of your social security number. This w ill be kept confidential
	by the New York State Department of Health and the Bureau of Emergency Medical Services.
12 .	SEX: M for male, F for female.
13 .	I f you are part of the teaching faculty for this course, check Yes.
14 .	AGENCY CODE: Fill in the Department of Health numerical code assigned to the agency w ith w hich you
	provide prehospital care.
15 .	PRACTI CAL SKI LLS EXAM DATE: Fill in the date( s) of your Practical Skills Exam. This date w ill be provided by
	the I nstructor/ Coordinator.
16 .	EXAMI NATI ON DATE: Fill in the date that you w ill be taking the NYS certifying exam. This date w ill be
	provided by the I nstructor/ Coordinator.
17 .	Read the statement and sign the application ( if able) as you normally sign your name, and w rite in today's
	date. You are responsible for the statement's truth and accuracy.

DOH- 65 ( 1/ 2009) page 2 of 2

Question	Answer
Form Name	Doh 65 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	doh65, ems application form, medical services certification form, fill doh nys forms ems

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