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
Contact Information

CLI/CIC Teaching Experience

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. 
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Section C Instructor Continuing Education Completed

Course # Date Topic or Course Description # of Hours Weight
Only plae your NYS approved courses hours here. Your additional, non-State hours, will be recorded in the next step. 
Please attach a PDF of your certification for the State mandated course here. 
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Course # Date Topic or Course Description # of Hours Weight
more items
Please add a PDF of your "other" hour certificate(s).
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Pre-Hospital Patient Care Experience

Agency you are actively providing on-going, direct, hands-on, pre-hospital patient care with. 
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. 
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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.

Sign above