Form Ems 0014 PDF Details

Form Ems 0014 is an important form that you will need to fill out if you are a self-employed individual or own your own business. This form is used to report income and expenses for your business, so it is important to make sure that everything is filled out correctly. If you are unsure of how to complete this form, be sure to speak with an accountant or tax specialist. By doing so, you can be sure that your return will be filed correctly and that you will receive the best possible tax refund. Thank you for reading!

QuestionAnswer
Form NameForm Ems 0014
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesEMS0014 does ohio have a grandfather clause for firefighter form

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OHIO DEPARTMENT OF PUBLIC SAFETY

EMERGENCY MEDICAL SERVICES

APPLICATION FOR GRANDFATHERED FIREFIGHTER

CERTIFICATE IN LIEU OF COMPLETION

All Information MUST be included. Incomplete applications WILL NOT be processed.

(Please print legibly and use black or blue ink.)

LAST NAME

 

 

 

 

 

 

FIRST NAME

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

COUNTY OF RESIDENCE

 

 

HOME PHONE NUMBER

 

WORK PHONE NUMBER

FAX NUMBER

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

Disclosure of social security number is mandatory

 

DATE OF BIRTH

E-MAIL ADDRESS

 

pursuant to R.C. 3123.50 in furtherance of licensing

 

 

 

 

 

 

 

 

 

provision and any other state or federal requirements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYING FIRE DEPARTMENT

 

 

 

 

PRIMARY DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT ADDRESS

 

 

 

 

 

 

 

 

DEPARTMENT PHONE NUMBER

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

STATE

ZIP CODE

COUNTY

 

 

 

 

 

 

 

 

 

 

 

POSITION

 

 

 

 

 

 

 

 

 

DATE OF APPOINTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

STATUS

 

 

 

 

 

 

 

 

 

 

 

 

FULL TIME PAID

 

 

 

 

 

 

 

 

 

 

 

 

VOLUNTEER

 

 

 

 

 

 

 

 

 

 

 

 

Attach proof that demonstrates you were a member of a Volunteer Fire Department prior to July 2, 1979 or a Paid Full Time Firefighter prior to July 2, 1970.

I attest that the information in this application is true and correct to the best of my knowledge. I hereby give permission to the Ohio Department of Public Safety, Division of Emergency Medical Services to verify any and all information.

APPLICANT SIGNATURE

X

DATE

Return to:

OHIO DEPARTMENT OF PUBLIC SAFETY

EMERGENCY MEDICAL SERVICES

P.O. Box 182073

Columbus, OH 43218-2073

(800) 233-0785 • (614) 466-9447 • Fax (614) 466-9461

EMS 0014 9/08

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