ARIZONA DEPARTMENT OF HEALTH SERVICES

DIVISION OF PUBLIC HEALTH SERVICES

BUREAU OF EMERGENCY MEDICAL SERVICES & TRAUMA SYSTEM
Application o! EMT R"c"!tiication
Please complete all information on this form and attach all documents listed as pertaining to your application.
Failure to provide all required information will result in delay in processing your application. A.A.C. R9-2-!2"!#$%
#!%
I# CERTIFICATION INFORMATION
&evel of '() Certification Currently *eld or with an '+piration ,ate within the Past -" ,ays.
'()-$asic '()-/ntermediate#99% '()-Paramedic
&evel of '() Certification for which Recertification /s Requested.
'()-$asic '()-/ntermediate#99% '()-Paramedic
II# APPLICANT INFORMATION
First 0ame (iddle 0ame &ast 0ame

1treet Address or P.2. $o+ City 1tate 3ip Code

*ome )elephone 0um4er Alternate )elephone 0um4er 1ocial 1ecurity 0um4er
!
,ate 2f $irth

III# APPLICANT CRIMINAL HISTORY INFORMATION$
YES NO A!" %o& c&!!"ntl%'
/ncarcerated for a criminal conviction5
2n parole for a criminal conviction5
2n supervised release for a criminal conviction5
2n pro4ation for a criminal conviction5
YES NO ()il" c"!tii"* a+ an EMT in A!i,ona- )a." %o& /""n con.ict"* o an% o t)" ollo0in1
c!i2"+- o! an% +i2ila!l% *"in"* c!i2"- in A!i,ona o! in an% ot)"! +tat" o! 3&!i+*iction4
!st or 2nd degree murder
Attempted !st or 2nd degree murder
1e+ual assault
Attempted se+ual assault
1e+ual a4use of a minor
Attempted se+ual a4use of a minor
1e+ual e+ploitation of a minor
Attempted se+ual e+ploitation of a minor
Commercial se+ual e+ploitation of a minor
Attempted commercial se+ual e+ploitation of a minor
(olestation of a child
Attempted molestation of a child
Any of the following committed against a minor under ! years of age #a dangerous crime against
children as defined in A.R.1. 6 !--7"8."!#(%%.
2nd degree murder
Aggravated assault resulting in serious physical in9ury or involving the discharge: use: or
threatening e+hi4ition of a deadly weapon or dangerous instrument
1e+ual assault
(olestation of a child
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Application o! EMT R"c"!tiication- Pa1" 5
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1e+ual conduct with a minor
Commercial se+ual e+ploitation of a minor
1e+ual e+ploitation of a minor
Child a4use as prescri4ed in A.R.1. 6 !---72-#A%#!%
?idnapping
1e+ual a4use
)a@ing a child for the purpose of prostitution as prescri4ed in A.R.1. 6 !---2"7
Child prostitution as prescri4ed in A.R.1. 6 !---2!2
/nvolving or using minors in drug offenses
Continuous se+ual a4use of a child
Attempted !st degree murder
1e+ traffic@ing
(anufacturing methamphetamine under circumstances that cause physical in9ury to a minor
$estiality as prescri4ed in A.R.1. 6 !--!8!!#A%#2%
YES NO (it)in 7 %"a!+ /"o!" t)" *at" o ilin1 t)i+ application- )a." %o& /""n con.ict"* o a
2i+*"2"ano! in.ol.in1 2o!al t&!pit&*" o! a "lon% in A!i,ona o! in an% ot)"! +tat" o!
3&!i+*iction- ot)"! t)an a 2i+*"2"ano! o! "lon% li+t"* a/o."4
YES NO (it)in 5 %"a!+ /"o!" t)" *at" o ilin1 t)i+ application- )a." %o& /""n con.ict"*- in A!i,ona
o! in an% ot)"! +tat" o! 3&!i+*iction- o a 2i+*"2"ano! in.ol.in1'
Possession: use: administration: acquisition: sale: manufacture: or transportation of an
into+icating liquor: dangerous drug:
2
or narcotic drug
-
5
,riving or 4eing in physical control of a vehicle while under the influence of an into+icating
liquor: dangerous drug: or narcotic drug5
$C)"c8 NO a/o." o! an% con.iction t)at )a+ /""n a/+ol&t"l% *i+c)a!1"*- "9p&n1"*- o! .acat"*#
IV# APPLICANT REGULATORY HISTORY INFORMATION
YES NO (it)in 7 %"a!+ /"o!" t)" *at" o ilin1 t)i+ application- )a." %o& )a* EMT c"!tiication o!
!"c"!tiication !".o8"* in A!i,ona o! EMT c"!tiication- !"c"!tiication- o! lic"n+&!" !".o8"*
in an% ot)"! +tat" o! 3&!i+*iction4
V# CITIZENSHIP OR NATIONAL STATUS DECLARATION
YES NO A!" %o& a citi,"n o! national o t)" Unit"* Stat"+4
8
:c)"c8 on";
P!o.i*" t)" ollo0in1 ino!2ation o 0)"!" %o& 0"!" /o!n
Cit% Stat" :o! "<&i.al"nt; Co&nt!% o! T"!!ito!%

VI# ATTESTATION AND SIGNATURE
/ the undersigned here4y declare: under penalty of per9ury as defined in AR1 6 !--2A"2#A%#2%: a class 8 felony:
that the answers / have given in this application addendum are true and correct.
SIGNATURE DATE
=

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Application o! EMT R"c"!tiication- Pa1" >
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VII# ATTACHMENTS RE?UIRED
I %o& an+0"!"* YES to an% <&"+tion in S"ction III# Applicant C!i2inal Hi+to!% Ino!2ation- attac) /ot) o t)"
ollo0in1 o! "ac) c!i2inal con.iction a/o&t 0)ic) %o& c)"c8"* YES'
A completed Criminal *istory AddendumB A0,
Certified copies: o4tained from the convicting court: of.
Cudgment of Conviction
1entencing ,ocuments #for original sentence and any later changes in sentence%
2rder of or ,ismissal from Pro4ation #if applica4le%
I %o& an+0"!"* YES to t)" <&"+tion in S"ction IV# Applicant R"1&lato!% Hi+to!% Ino!2ation- attac) t)" ollo0in1 o!
"ac) EMT c"!tiication- !"c"!tiication- o! lic"n+&!" !".o8"*'
A completed Regulatory *istory AddendumB A0,
A copy of the Final 2rder or Administrative Ruling that included the revocation
A+ pa!t o t)" application- %o& 0ill n""* to p!o.i*" on" *oc&2"nt i*"ntii"* in t)" attac)"* p&/lic /"n"it "li1i/ilit%
+tat&+ @P!i2a!% E.i*"nc"A cat"1o!i"+- o 0)ic) t)" *oc&2"nt can /" a l"tt"! :a cop% i+ acc"pta/l"; !o2 %o&!
"2plo%"! a+ p!oo o US citi,"n+)ipB"li1i/ilit% to 0o!8 i t)" l"tt"! 2""t+ t)" c!it"!ia /"lo0#
)his one time verification will only 4e required 4y the $ureau on initial applications and the first recertification application
received after April !: 2""D. <our future recertification will not require this documentation as your records will 4e on file.
Copi"+' )he $ureau will accept legi4le copies of the documents descri4ed in the pu4lic 4enefit eligi4ility status
category list.
E2plo%"! L"tt"!. )he $ureau will accept a letter #a copy is accepta4le% from your employer as proof of >1
citiEenshipFeligi4ility to wor@ if it contains all of the following.
/s datedB
A signature 4y an authoriEed representative of the companyB
Contains your full nameB
/s printed on your employerGs letterheadB
Attests that you are an employee: and
)he letter states that your employer has verified your lawful presence in the >nited 1tates and eligi4ility to
receive state or local pu4lic 4enefits as required 4y Federal and 1tate statutes.
I %o& )ol* EMT c"!tiication- !"c"!tiication- o! lic"n+&!" in anot)"! +tat" o! 3&!i+*iction- attac)'
A copy of each '() certification: recertification: or licensure held
I %o& a!" appl%in1 o! EMTCBa+ic !"c"!tiication- attac) "it)"!'
A certificate of course completion signed 4y the training program director designated for the course session showing
that within 2 years 4efore the e+piration date of your certificate: you completed either.
)he AriEona '()-$ Refresher: 2R
)he AriEona '()-$ Refresher Challenge '+aminationB 2R
'vidence of current 0R'()-$asic registration
I %o& a!" appl%in1 o! EMTCInt"!2"*iat" :DD; !"c"!tiication- attac) "it)"!'
A completed Continuing 'ducation Attestation Form: 2R
'vidence of current 0R'()-/ntermediateF99 registration
I %o& a!" appl%in1 o! EMTCPa!a2"*ic !"c"!tiication- attac) "it)"!'
A completed Continuing 'ducation Attestation Form: 2R
'vidence of current 0R'()-Paramedic registration
I %o& a!" appl%in1 o! !"c"!tiication 0it)in >E *a%+ at"! t)" "9pi!ation *at" o %o&! c"!tiicat"- attac)'
A certified chec@: 4usiness chec@: or money order for H!" made paya4le to the AriEona ,epartment of *ealth
1ervices.
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Application o! EMT R"c"!tiication- Pa1" F
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LIST A
PUBLIC BENEFIT ELIGIBILITY STATUS PRIMARY EVIDENCE
#!% A letter from your employer verifying >.1 .citiEenship or national status and eligi4ility to wor@ containing the
following. #!% Current dateB and #2% A signature 4y an authoriEed representative of the companyB and #-% )he
applicants full nameB and #-% /s printed on the employerGs letterheadB and #8% )he employer attests that the applicant
is an employeeB and #% )he letter states that your employer has verified your lawful presence in the >nited 1tates
and eligi4ility to receive state or local pu4lic 4enefits as required 4y Federal and 1tate statutes.
#-% A 4irth certificate showing 4irth in one of the " states: the ,istrict of Colum4ia: Puerto Rico #on or after Canuary
!-: !98!%: ;uam: the >.1. Iirgin /slands #on or after Canuary !A: !9!A%: American 1amoa: or the 0orthern (ariana
/slands #on or after 0ovem4er 8: !9D7: 0orthern (ariana /sland local time% #unless the applicant was 4orn to
foreign diplomats residing in such a 9urisdiction%B
#8% >nited 1tates passportB
#% Report of 4irth a4road of a >.1. citiEen #F1-28"% #issued 4y the ,epartment of 1tate to >.1. citiEens%B
#7% Certificate of $irth #F1-8% #issued 4y a foreign service post% or Certification of Report of $irth #,1-!-"%:
copies of which are availa4le from the ,epartment of 1tateB
#A% Form 0-7!: Certificate of CitiEenshipB
#D% Form /-!9A: >nited 1tates CitiEen /dentification Card #issued 4y the 1ervice until April A: !9D- to >.1. citiEens
living near the Canadian or (e+ican 4order who needed it for frequent 4order crossings% #formerly Form /-!A9: last
issued in Fe4ruary !9A8%B
#9% Form /-DA- #or prior versions%: 0orthern (arianas Card #issued 4y the 1ervice to a collectively naturaliEed >.1.
citiEen who was 4orn in the 0orthern (ariana /slands 4efore 0ovem4er -: !9D7%B
#!"% 1tatement provided 4y a >.1. consular official certifying that the individual is a >.1. citiEen #given to an
individual 4orn outside the >nited 1tates who derives citiEenship though a parent 4ut does not have an F1-28": F1-
8: or ,1-!-"%B or
#!!% Form /-DA2 #or prior versions%: American /ndian Card with a classification code J?/CK and a statement on the
4ac@ identifying the 4earer as a >.1. citiEen #issued 4y the 1ervice to >.1. citiEen mem4ers of the )e+as $and of
?ic@apoos living near the >.1.F(e+ican 4order%.
LIST B
PUBLIC BENEFIT ELIGIBILITY STATUS SECONDARY EVIDENCE
/f the applicant cannot present one of the documents listed under JPrimary 'videnceK: a4ove: the following may
4e relied upon to esta4lish >.1. citiEenship or nationality in com4ination with one from &ist JAK.
#!% Religious record recorded in one of the " states: the ,istrict of Colum4ia: Puerto Rico #on or after Canuary !-:
!98!%: ;uam: the >.1. Iirgin /slands #on or after Canuary !A: !9!A%: American 1amoa: or the 0orthern (ariana
/slands #on or after 0ovem4er 8: !9D7: 0orthern (ariana /slands local time% #unless the applicant was 4orn to
foreign diplomats residing in such a 9urisdiction% within three - months after 4irth showing that the 4irth occurred in
such 9urisdiction and the date of 4irth or the individualGs age at time the record was madeB
#2% 'vidence of civil service employment 4y the >.1. government 4efore Cune !: !9A7B
#-% 'arly school records #prefera4ly from the first school% showing the date of admission to the school: the
applicantGs date and >.1. place of 4irth: and the name#s% and place#s% of 4irth of the applicantGs parents#s%B
#8% Census record showing name: >.1. nationality or a >.1. place of 4irth: and applicantGs date of 4irth or ageB
#% Adoption finaliEation papers showing the applicantGs name and place of 4irth in one of the " states: the ,istrict
of Colum4ia: Puerto Rico #on or after Canuary !-: !98!%: ;uam: the >.1. Iirgin /slands #on or after Canuary !A:
!9!A%: American 1amoa: or the 0orthern (ariana /slands #on or after 0ovem4er 8: !9D7: 0orthern (ariana /slands
local time% #unless the applicant was 4orn to foreign diplomats residing in such a 9urisdiction%: or: when the adoption
is not finaliEed and the state or other >.1. 9urisdiction listed a4ove will not release a 4irth certificate prior to final
adoption: a statement from a 1tate-or 9urisdiction-approved adoption agency showing the applicantGs name and
place of 4irth in one of such 9urisdictions: and stating that the source of the information is an original 4irth certificateB
#7% Any other document that esta4lishes a >.1. place of 4irth or otherwise indicates >.1. nationality #e.g.: a
contemporaneous hospital record of 4irth in that hospital in one of the " states: the ,istrict of Colum4ia: Puerto
Rico #on or after Canuary !-: !98!%: ;uam: the >.1. Iirgin /slands # on or after Canuary !A: !9!A%: American
1amoa: or the 0orthern (ariana /slands #on or after 0ovem4er 8: !9D7: 0orthern (ariana /slands local time%
#unless the applicant was 4orn to foreign diplomats residing in such a 9urisdiction%B
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LIST C
PUBLIC BENEFIT ELIGIBILITY STATUS
/f the applicant cannot present documents listed in A or $ a4ove: the following will esta4lish >.1. citiEenship for
collectively naturaliEed individuals.
'vidence of 4irth in Puerto Rico on or after April !!: !D99 and the applicantLs statement that he or she was residing
in the >.1.: a >.1. possession or Puerto Rico on Canuary !-: !98!B or
'vidence that the applicant was a Puerto Rican citiEen and the applicantLs statement that he or she was residing in
Puerto Rico on (arch !: !9!A and that he or she did not ta@e an oath of allegiance to 1pain. >.1. Iirgin /slands.
'vidence of 4irth in the >.1. Iirgin /slands: and the applicantLs statement of residence in the >.1.: a >.1.
possession or the >.1. Iirgin /slands on Fe4ruary 2: !92AB
'vidence of the applicantLs residence in the >.1. Iirgin /slands as a ,anish citiEen on Canuary !A: !9!A and
residence in the >.1.: a >.1. possession or the >.1. Iirgin /slands on Fe4ruary 2: !92A: and that he or she did not
ma@e a declaration to maintain ,anish citiEenshipB or
'vidence of 4irth in the >.1. Iirgin /slands and the applicantLs statement indicating residence in the >.1.: a >.1.
possession or territory or the Canal 3one on Cune 2D: !9-2. 0orthern (ariana /slands #0(/% formerly part of the
)rust )erritory of the Pacific /sland #))P/%.
'vidence of 4irth in the 0(/: ))P/ citiEenship and residence in the 0(/: the >.1.: or a >.1. territory or possession
on 0ovem4er -: !9D7 #0(/ local time% and the applicantLs statement that he or she did not owe allegiance to a
foreign state on 0ovem4er 8: !9D7 #0(/ local time%B or
'vidence of ))P/ citiEenship: continuous residence in the 0(/ since 4efore 0ovem4er -: !9D! #0(/ local time%:
voter registration prior to Canuary !: !9A and the applicantLs statement that he or she did not owe allegiance to a
foreign state on 0ovem4er 8: !9D7 #0(/ local time%B or
'vidence of continuous domicile in the 0(/ since 4efore Canuary !: !9A8 and the applicantLs statement that he or
she did not owe allegiance to a foreign state on 0ovem4er 8: !9D7 #0(/ local time%. 0ote. /f a person entered the
0(/ as a non-immigrant and lived in the 0(/ since Canuary !: !9A8: this does not constitute continuous domicile
and the individual is not a >.1. citiEen.
LIST D
PUBLIC BENEFIT ELIGIBILITY STATUS
/f the applicant cannot present documents listed in A: $ or C a4ove: the $ureau may ma@e a determination of
derivative >.1. citiEenship in the following situations.
Applicant 4orn a4road to two >.1. citiEen parents with evidence of the >.1. citiEenship of the parents and the
relationship of the applicant to the parents and evidence that at least one parent resided in the >.1. or an outlying
possession prior to the applicantLs 4irth.
Applicant 4orn a4road to a >.1. citiEen parent and a >.1. non-citiEen national parent with evidence that one parent
is a >.1. citiEen and that the other is a >.1. non-citiEen national: evidence of the relationship of the applicant to the
>.1. citiEen parent: and evidence that the >.1. citiEen parent resided in the >.1.: a >.1. possession: American
1amoa or 1wainGs /sland for a period of at least one year prior to the applicantLs 4irth.
Applicant 4orn out of wedloc@ a4road to a >.1. citiEen mother with evidence of the >.1. citiEenship of the mother:
evidence of the relationship to the applicant and: for 4irths on or 4efore ,ecem4er 28: !92: evidence that the
mother resided in the >.1. prior to the applicantLs 4irth or: for 4irths after ,ecem4er 28: !92: evidence that the
mother had resided: prior to the childLs 4irth: in the >.1. or a >.1. possession for a period of one year.
Applicant 4orn in the Canal 3one or the Repu4lic of Panama: a 4irth certificate showing 4irth in the Canal Eone on
or after Fe4ruary 27: !9"8 and 4efore 2cto4er !: !9A9 and evidence that one parent was >.1. citiEen at the time of
the applicantLs 4irthB or a 4irth certificate showing 4irth in the Repu4lic of Panama on or after Fe4ruary 27: !9"8 and
4efore 2cto4er !: !9A9 and evidence that at least one parent was a >.1. citiEen and employed 4y the >.1.
government or the Panama Railroad Company or its successor in title.
All ot)"! +it&ation+ 0)"!" an applicant clai2+ to )a." a U#S# citi,"n pa!"nt an* an ali"n pa!"nt- o! clai2+ to
all 0it)in on" o t)" a/o." cat"1o!i"+ /&t i+ &na/l" to p!"+"nt t)" li+t"* *oc&2"ntation +)all /" !""!!"*
to t)" local INS oic" o! *"t"!2ination o U#S# citi,"n+)ip#
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Application o! EMT R"c"!tiication- Pa1" G
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LIST E
PUBLIC BENEFIT ELIGIBILITY STATUS
An applicant: who is not a citiEen or national of the >nited 1tates: 4ut declares either a non-e+empt Mqualified
alienM status or a specific category of qualified alien: nonimmigrant: and a certain alien paroled into the >nited
1tates: provide a legi4le copy document with photograph listed 4elow that evidences eligi4ility status.
H?&alii"* Ali"nH Stat&+ :I U#S#C#J IG5K:a;:K;- CIGFK:/; an* :c;
An alien lawfully admitted for permanent residence under the /mmigration and 0ationality Act #/0A%.
An alien who is granted asylum under 1ection 2"D of the /0A.
H?&alii"* Ali"nH Stat&+ :I U#S#C#JJ IG5K:a;:K;- CIGFK:/; an* :c; :Contin&"* !o2 pa1" K;
A refugee admitted to the >nited 1tates under 1ection 2"A of the /0A
An alien paroled into the >nited 1tates for at least one year under 1ection 2!2#d%#% of the /0A.
An alien whose deportation is 4eing withheld under 1ection 28-#h% of the /0A.
An alien granted conditional entry under 1ection 2"-#a%#A% of the /0A as in effect prior to April /: !9D"
An alien who is a Cu4an and *aitian entrant #as defined in section "!#e% of the Refugee 'ducation Assistance Act
of !9D"%.
An alien who is: or whose child or childLs parent is a M4attered alienM or an alien su49ected to e+treme cruelty in the
>nited 1tates.
Noni22i1!ant Stat&+ :I U#S#C#J KG5K:a;:5;;
A nonimmigrant under the /mmigration and 0ationality Act ND >.1.C. 6 !!"! et seq.O 0onimmigrants are persons
who have temporary status for a specific purpose. 1ee D >.1.C. 6 !!"!#a%#l%.
Alien Paroled into the >nited 1tates For &ess )han 2ne <ear #D >.1.C.6 !72!#a%#-%%
An alien paroled into the >nited 1tates for less than one year under 1ection 2!2#d%#% of the /0A
Ot)"! P"!+on+ :I U#S#C#J KG5K:c;:5;:A; an* :C;;
A nonimmigrant whose visa for entry is related to employment in the >nited 1tates: or
A citiEen of a freely associated state: if section !8! of the applica4le compact of free association approved in Pu4lic
&aw 99-2-9 or 99-7D #or a successor provision% is in effect NFreely Associated 1tates include the Repu4lic of the
(arshall /slands: Repu4lic of Palau and the Federate 1tates of (icronesia: 8D >.1.C. 6 !9"! et seq.];
A foreign national not physically present in the >nited 1tates.
Ot)"!0i+" La0&ll% P!"+"nt :A#R#S# J KC7EK;
A person not descri4ed in categories !-!- who is otherwise lawfully present in the >nited 1tates. PLEASE NOTE'
)he federal Personal Responsi4ility and =or@ 2pportunity Reconciliation Act may ma@e persons who fall into this
category ineligi4le for licensure. 1ee D >.1.C. 6 !72!#a%.
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!
An applicant must provide the applicantGs social security num4er: as required under A.R.1. 66 2--2"#0% and 2-"2#?%. A,*1 does
not include a social security num4er on an '() certificate. A,*1 uses social security num4ers for purposes of identifying applicants
and will not release a social security num4er e+cept as permitted under federal or state law.
2
J,angerous drugK is defined in A.R.1. 6 !---8"!.
-
J0arcotic drugK has the same meaning as Jnarcotic drugs:K as defined in A.R.1. 6 !---8"!.
8
JFederal and 1tate statutory requirementsB D >.1.C. 6 !7!!: !72! and A.R.1. 6!-"!requires: in general: that a person applying for a
license must su4mit documentation to the licensing agency that satisfactorily demonstrates that the applicant is lawfully present in the
>nited 1tates.
.