EMT License Renewal Application

EMT License Renewal Application
Submit your application to renew your Emergency Medical Technician (EMT) license. Please complete all required fields accurately.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Current EMT License Number
Current EMT License Expiration Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer/Agency Name
Have you completed the required continuing education or refresher training for this renewal period?
Upload proof of continuing education or refresher training
Cancelof
Have you been convicted of any crimes or had disciplinary actions since your last renewal?
If yes, please provide details
Applicant Signature
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