Form Doh 4453 PDF Details

In the intricate landscape of emergency medical services, the DOH 4453 form emerges as a crucial document for Emergency Medical Technicians (EMTs) within New York State. Managed by the Bureau of Emergency Medical Services under the New York State Department of Health, this form facilitates the request for duplicate certification cards, a necessity in cases where the original card is lost, damaged, or requires updating due to personal information changes such as name or address adjustments. Applicants are required to meticulously provide their EMT number, the expiration date of their certification, alongside comprehensive personal information including their date of birth, contact details, and a declaration concerning any misdemeanors or felonies as per the requirements of 10NYCRR Part 800. The importance of this form underscores not only the procedural rigor in maintaining the integrity and accuracy of EMT credentials but also the legal and ethical standards expected from those in the lifesaving profession. Moreover, the stipulation that applications must be faxed or mailed, with an original signature, highlights a critical security measure in protecting personal information and maintaining the credibility of the certification process. Thus, the DOH 4453 form exemplifies the meticulous balance between operational efficiency, legal compliance, and the safeguarding of personal and professional integrity within the emergency medical services sector.

QuestionAnswer
Form NameForm Doh 4453
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesEMS, NY, applicable, Suffix

Form Preview Example

NEW YORK STATE DEPARTMENT OF HEALTH

Bureau of Emergency Medical Services

Duplicate Card Request

Please type or print

EMT Number

Expiration Date

Name

Name

Change

Address

Last and Suffix

First and Middle Initial

Address

Change

City

County

Number and Street

Apartment Number

Date of

Birth

State

Sex

Zip

Phone

Number

Please Fax or Mail to

Certification Unit

Bureau of EMS

875 Central Ave.

Albany, NY 12206

FAX 518-402-0985

I affirm that in accordance with the requirements of 10NYCRR Part 800. (e), I have not been convicted of or am not currently charged with 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 10NYCRR Part 800.

Signature_______________________________________ Date______________________

“DO NOT E-MAIL” original signature required

DOH-4453 (9/08)

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Certification Unit Bureau of EMS, Number, and DO NOT EMAIL original signature of form doh 4453

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