APPLICATION FOR EMT/PARAMEDIC CERTIFICATION
APPLICATION FOR EMT/PARAMEDIC . CERTIFICATION : Emergency Medical Technician (2501). paramedic (2502). Please TYPE or PRINT in ink. Read instructions carefully before completing. All sections of this APPLICATION are required to be completed unless otherwise noted. Omissions may delay processing. 1. APPLICANT INFORMATION. ________________________________________ ________________________________________ __________/____/____. Last Name First Name Middle Initial Date of Birth ________________________________________ ________________________________________ ___________________. Mailing Address for correspondence City State Zip Code If your mailing address is a Box, provide your street address as well. Day time phone # (____)_________ Home phone # (_____)_________ Email___________________________________ _.
affiliated person of the applicant currently enrolled in a pretrial diversion or drug court program that allows for the withdrawal of the plea or dismissal of the charges for the DH FORM 1583, 04/2017, Rule 64J-1.008 F.A.C. | Page 3
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