If you are certifying with S-SV EMS for the first time you are considered an Initial certification
according to EMSA California Code of Regulations, Title 22, Division 9, Chapter 10 states the
following §100345. Fees. The following fees shall apply:
(1) $75 per initial EMT or Advanced EMT certificate or per an applicant whose criminal
background check from the DOJ is no longer active. Subsection (a)(1) applies to those EMTs that
change certifying entities when they recertify. Once they leave their previous LEMSA,
their Background check is no longer considered "active." This also applies to LEMSAs that did not
previously do Background checks.
EMT/AEMT CERTIFICATION
APPLICANT INFORMATION - Please complete the fields below
Full Name:
Date of Birth:
SSN:
Phone:
Address:
City:
State:
Zip Code:
Is this a change in address?
YesNo
Work Phone:
EMAIL:
CERTIFICATION/RE-CERTIFICATION INFORMATION
Current Certification Number (if recertifying):
Expiration Date:
Previous Certifying Entity (if recertifying):
EMPLOYMENT
If employed by EMS Provider please list Provider name & address:
Address:
City:
State:
Zip Code:
Have you ever been convicted of any felony or misdemeanor offense in California or in any other state or place, including entering a plea of nolo contendere or no contest and, including any conviction which has been expunged (set aside) under Penal Code Section 1230.4?
YesNo
Are there any criminal charges currently pending against you?
YesNo If you answered yes to either of these questions, you must provide a detailed statement describing the crime(s), date, location, court, and/or remediation as a result of the action. (may attach court documents)
Have you ever had certification, accreditation, or professional healing arts license denied, suspended, revoked or placed on probation, or are you under investigation at this time?
YesNo If yes, you must enclose with this application a written explanation that describes the action, any corrective action, and/or mediation as a result of the action. (may attach court documents)
SIGNATURES
I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to EMT certification the state of California. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as an EMT in California.
Online Signature of Applicant:
Date:
STATEMENT OF CONTINUING EDUCATION - MINIMUM OF 24 HOURS REQUIRED
May include CE course, class or online instruction; any topic relevant to emergency medical care. Certificates must be kept for four years.
