Paramedic Reaccreditation Application -

Name *

First

Middle

Last

Mailing Address *

Address Line 1

City

State

Zip Code

Email Address *

Telephone Number *

California Paramedic License Number *

California Paramedic License Expiration Date *

ALS Employer (enter "N/A" or "None" if not applicable) *

How Many Application File Attachments Do You Have To Upload? (3 MB Max File Size Per Attachment)

Please see "Reaccreditation Instructions" on the previous page for a list of required documents. Any documents that are unable to be uploaded can be e-mailed to our mailbox: INFO @ ssvems.com

Attestation and Electronic Signature

By typing my name in the signature box and entering today's date, I hereby certify under penalty of perjury that all information is true and correct to the best of my knowledge and belief. I understand that any falsification or omission of material facts may cause forfeiture on my part of all right to paramedic accreditation by the S-SV EMS Agency. I understand all information on this application is subject to verification, and I hereby give my express permission for the S-SV EMS Agency to contact any person or agency for information related to my role and function as a paramedic.

Signature *

Date *

Name