HomeMy WebLinkAboutparamedic-accreditation-applicationAlameda County EMS Revised: October 16, 2017 Page 1 of 1
ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY Paramedic Accreditation Application
Name:
Last First MI
Address: Street City State Zip County
Home Phone: _______________________ Cell Phone: _______________________ Email:
D.O.B:_______________________ SSN: _______________________ Driver’s License #: _________________
(MM/DD/YYYY)
Employer: ________________________________________________________________________________________________________
California Paramedic License #: Paramedic License Expiration Date:_______________________
(MM/DD/YYYY)
Total number of years of experience as a paramedic:
Number of years of experience as a paramedic in Alameda County:
List all counties where you have been accredited:
1. ___________________________________________________ 2. ___________________________________________________
3. ___________________________________________________ 4. ___________________________________________________
Alameda County orientation attended Date: _______________________ (MM/DD/YYYY)
Expanded scope/local optional scope of practice training completed Date:
I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to paramedic accreditation in Alameda
County. I understand all information on this application is subject to verification, and I hereby give my express permission for this certifying entity to contact any person or agency for information related to my role and function as a paramedic in Alameda County.
Sign here: Date:
This section to be completed by a designated representative of the provider agency.
This is to verify that this individual meets all requirements of Title 22, Chapter 4 and Alameda County EMS policies pertaining to accreditation. Supporting documentation is on file and available upon request.
Sign here: Date:
Print Name: Provider:
Did you…
Payment may be made by credit card online; or with a money order, cashier’s check, or municipal purchase order payable to: Alameda County EMS Agency. We do not accept personal checks or cash.
Alameda County EMS, 1000 San Leandro Blvd. Suite 200, San Leandro, CA 94577
For Further Information:
The Alameda County EMS web site is at http://www.acphd.org/ems.aspx
To view the Paramedic Local Accreditation Policy go to http://www.acphd.org/emtpara/certification-and-accreditation/paraaccre.aspx
To read a list of frequently asked questions about paramedic accreditation