
Initial EMT Certification Fee -
75*:
SSN
Last First
Birth Date
City State Zipcode ___________
Phone
Documentation attesting to current CPR credentials Proof of completion of a state approved course
NREMT Registry #
For ATP Applicants ONLY:
► Do you hold any other license(s) or certificate(s)? __ Yes __ No
►
__ Yes __ No
►
Are there any criminal charges pending against you
__ Yes __ No
►
or been denied a certificate or license? __ Yes __ No
►
against you? __ Yes __ No
► Have you ever voluntarily surrendered a certificate or license for any reason? __ Yes __ No
► Have you ever had a certification, accreditation or professional healing arts license suspended, revoked
or placed on probation; and/or are you currently under investigation? __ Yes __ No
Copy of your Federal or State Government
Issued Photo Identification
CERIFICATIONS
Date IssuedCertificate/License NumberKind of Certificate/License and State of Issuance
EMT-Paramedic Applicants: Documentation
attesting to current ACLS credentials.
Passed Advanced Tactical Practitioner written
exam and hold current credentials.
EMS OUT-OF-STATE LICENSURE APPLICATION
GEORGIA STATE OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA
Form C-08-B
APPLICATION – PRINT IN INK OR TYPE
BASIC
Mail application
and required
documents to:
State Office of EMS and Trauma
ATTN: Personnel Licensure
2600 Skyland Drive - Lower Level
Atlanta, GA 30319
INTERMEDIATE 85
PARAMEDIC
______ - _______ - _________
County _______________
* The non-refundable fee must accompany this application. Payment must be in the form of Money Order, Business Check
or Cashier's Check Only. MAKE ALL FEES PAYABLE TO "GEORGIA DEPARTMENT OF PUBLIC HEALTH"
PERSONAL INFORMATION
Legal Name _______ - _____ - __________
All applications are processed within 5-7 business days from the date received.
Copy of current NREMT Wallet Card
Reinstatement Certification Fee
Lapse ≥ 2yr of Certification - $150*
_________________________
(______) _______ - __________ E-Mail ____________________________________________________
CERTIFICATION REQUIREMENTS - Applicant shall provide all listed information and/or documents
M.I.
Address
and/or remediation as a result of the action.
BACKGROUND DISCLOSURE
Have you ever been arrested and/or convicted of any National, Federal, State or Local felony and/or
If you answered yes to either of the above questions, attach a detailed written statement, signed and dated, describing the crime(s),
misdemeanor offense in Georgia or in any other state or place?
Have you ever been denied the privilege of taking an examination given by any state licensing board
date, location, court, sentence served, and parole, if any. Attach copies of all related records, court documents and police reports.
Congratulations! Your willingness to serve Georgia’s citizens as an EMS professional is appreciated!
Current NATIONAL CRIMINAL HISTORY REPORT generated
no earlier than twelve (12) months prior to submitting an
application for licensure that includes your name, birthdate and
at least part of your SSN. Internet searches meeting the above
criteria are accepted.
Have you ever resigned from any employment after a complaint or peer review action has been initiated
If you answered yes, attach a detailed written statement, signed and dated, describing the event, investigation, action, any corrective action,
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
GEORGIA DEPARTMENT
OF PUBLIC HEALTH
Division of Em ergency
Preparedn ess & Response