ATTENTION: If you answer yes to any of the following background questions, you must attach or submit a letter of explanation.
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 EMR certification in the state of California. 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 an EMR. I understand that I may be required to provide copies of legal records related to my past criminal activity (if applicable), and the processing of my application may be delayed until these documents are provided to the satisfaction of the S-SV EMS Agency, I understand that I am solely responsible for notifying the S-SV EMS Agency in writing, within (30) calendar days, of any and all changes of my mailing address.