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Application for Instructor Recertification
Instructions
This application must be completed and signed prior to recertification. Please print or type all information in the spaces provided. Failure to properly complete this application may result in a delay in recertification.
Please review the recertification requirements in EMS Policy Satement 22-02, EMS Instructor Training Requirements & Certification Process.
Applicant Information
I am renewing my
CLI
CIC
Certified Lab Instructor #
Certified Instructor Coordinator #
EMT #
Contact Information
Name (Last, First Middle Initial)
Email
Phone
Address
Address 2
City/Town
State/Province
- Select -
Alabama
Alaska
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Hawaii
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Illinois
Indiana
Iowa
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Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
County
- Select -
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond
Rockland
St. Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming
Yates
Social Security #
Last four digits.
Date of Birth
CLI/CIC Teaching Experience
Course Sponsor Number
Laboratory Instructor for course number(s)
CIC of record for course number(s)
Course Sponsor Affirmation
Upload
Attach letter from Course Sponsor Administration that attests to the courses you were involved with either as a CLI, or as the CIC of record if applicable. It must be signed on the sponsor's letterhead.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Section C Instructor Continuing Education Completed
Mandatory State Approved CIU Course(s)
Re-order
Course #
Date
Topic or Course Description
# of Hours
Weight
Operations
Course #
Date
Topic or Course Description
# of Hours
Item weight
Remove item 1
Only plae your NYS approved courses hours here. Your additional, non-State hours, will be recorded in the next step.
State CIU Certificate Upload
Upload
Please attach a PDF of your certification for the State mandated course here.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Other Education Hours
Re-order
Course #
Date
Topic or Course Description
# of Hours
Weight
Operations
Course #
Date
Topic or Course Description
# of Hours
Item weight
Add new item after item 1
Remove item 1
Add
Add more items
more items
Other Certificates
Upload
Please add a PDF of your "other" hour certificate(s).
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Pre-Hospital Patient Care Experience
Name of EMS Agency
Agency you are actively providing on-going, direct, hands-on, pre-hospital patient care with.
Agency Code
Affirmation of Patient Care
Upload
Upload letter from Chief Operation Officer, or equivilant Supervisor, attesting to the fact that you are actively providing on-going, direct, hands-on pre-hospital patient care.
Letter needs to be on agency letter head and must be signed.
Upload requirements
One file only.
100 MB limit.
Allowed types:
txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods
.
Date you started with the agency
End date at the agency
Leave blank if you are still active at this agency.
Personal Affirmation
I affirm that in accordance with the requirements of 10 NYCRR 800, I have NOT been convicted of any misdemeanors or felonies. I understand that if I have a conviction it will be individually reviewed and that any such conviction may not be an automatic bar to certification. The Department of Health will determine if the conviction is applicable under the provisions of Part 800.
DO NOT SIGN IF YOU HAVE ANY CONVICTIONS.
I hereby certify that all of the information contained in this application is true and correct and that the signature below is mine as applicant. I further understand that offering or providing false information on this document may constitute a crime under the penal law and may subject any certification to revocation or other Department action.
Applicant's Signature
Reset
Sign above
Submit
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