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S-SV EMS Agency
Butte, Colusa, Glenn, Nevada, Placer, Shasta, Siskiyou, Sutter, Tehama & Yuba Counties
(916) 625-1702
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Information Date Signature
Applicant Information
Date / Time
*
Date
Time
Name
*
First
Last
Phone
*
Email
*
Incident Information
Authorization for temporary recognition is requested for the following medical personnel assigned to:
Incident Name
*
County(s) of Incident
*
Butte
Colusa
Glenn
Nevada
Placer
Shasta
Siskiyou
Sutter
Tehama
Yuba
Incident Start Date
Incident End Date
Personnel
Name
*
Certifcation/License
EMT
Paramedic
EMT/Paramedic #
Issuing Agency
Electronic Signature
Medical Unit Leader
*
First
Last
Medical Director
*
First
Last
Agency
LEMSA
Phone
Phone
Fax
Fax
Date / Time
Date
Time
Date / Time
Date
Time
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