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Healt: Florida Department of

This document is a form used by the Florida Department of Health to verify an EMT or paramedic applicant's certification status from another state. Part I is completed by the applicant providing their name, social security number, address and the state their current certification is from. Part II must be completed by the certifying agency of the other state. It requires the agency to verify the applicant's certification is current and in good standing, has not been revoked or suspended, and whether there is any reason certification should be denied in Florida. The completed form should then be mailed or faxed to the Florida EMT/Paramedic Certification Office.

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Nancy Reuter
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31 views1 page

Healt: Florida Department of

This document is a form used by the Florida Department of Health to verify an EMT or paramedic applicant's certification status from another state. Part I is completed by the applicant providing their name, social security number, address and the state their current certification is from. Part II must be completed by the certifying agency of the other state. It requires the agency to verify the applicant's certification is current and in good standing, has not been revoked or suspended, and whether there is any reason certification should be denied in Florida. The completed form should then be mailed or faxed to the Florida EMT/Paramedic Certification Office.

Uploaded by

Nancy Reuter
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FLORIDA DEPARTMENT OF

HEALT
STATEMENT OF GOOD STANDING This form is used to verify the good standing of EMT or paramedic certification applicants who are certified by another state or United States territory. It is the applicant's responsibility to send this to his or her certifying state. Do not attempt to have this form filled out unless you are using your certification or licensure from another state as evidence of your satisfaction of the Florida's professional education requirements for EMT or paramedic (C.2. on page 1 of the application). Part I (Completed by Applicant) Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .sS#_ _ _ _ _ _ _ _ __ Current Address, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ I am requesting Florida certification based on certification in the following state or territory: State._ _ _ _ _ _ _ _ _ . Cert #_ _ _ _ _ _ _ _ Exp. Oate_ _ _ _ _ _ __

Part II (Must Completed by the State Certifying Agency) Please assist by verifying that the above named individual is currently certified and in good standing according to your certification pOlicies. A. B. Is the above individual's certificate(s) deemed current and valid according to your policy? DYes 0 No Has the above certificate(s) ever been revoked or suspended? Yes If so, please explain and attach documentation 0 No

C.

Has the above individual ever been convicted of a felony? D Yes Offense and date of conviction if known:

No

D.

Do you know of any reason certification in Florida should be denied? (current investigation) DYes D No Ifyes,why?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Verifying Person's Name and Title_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Signature of Verifying Person_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Agency Name and State_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Phone Number_ _ _ _ _ _ _ _ _ _ __ Oate_ _ _ _ _ _ _ _ _ __

Please mail or fax to: EMT/Paramedic Certification Office 4052 Bald Cypress Way, Bin # C85 Tallahassee, Florida 32399-3285

OH 1583, 8/07

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