MICN Reauthorization Application

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 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 MICN Authorization 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 MICN in the S-SV EMS Region.