Fill - Free fillable 911 Public Safety Telecommunicator Initial/Original Certificate Application This (Florida Department of Health) PDF form

911 Public Safety Telecommunicator Initial/Original Certificate Application

This form in incorporated by reference in rule 64J-3.001

TYPE OR PRINT CLEARLY. All sections of this application are required to be completed unless otherwise noted. Omissions will

delay processing. PLEASE RETURN COMPLETED APPLICATION ALONG WITH YOUR NONREFUNDABLE $50 FEE.

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Page 1 of 4 DH5066, 01/12

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APPLICATION FEES ARE NOT REFUNDABLE

A. APPLICANT INFORMATION

Last Name First Name M.I. Date of Birth

Mailing Address City State Zip Code

Phone Number Email Address

B. PERSONAL INFORMATION (Optional)

Gender:

Female Male

Ethnicity:

Other Asian/Pacific Islander Native American Hispanic Black White

C. EMPLOYMENT STATUS

I am NOT currently employed as a 911 PST.

I am currently employed as a 911 PST by:

Agency Name:

Agency Address:

I request information about the status of my application be reported only to me

I authorize my employer to inquire and receive information as to the status of my application.

Page 2 of 4 DH5066, 01/12

APPLICATION FEES ARE NOT REFUNDABLE

D. EXAM QUALIFICATIONS

Choose one of the following options:

I have completed a department approved 911 PST training program as defined in Section

401.465(1)(c), Florida Statutes. I have attached a copy of the certificate of completion received

from the training program.

Training Program Attended:

Completion Date:

I was employed as a 911 public safety telecommunicator [as defined in Section 401.465(1)(a)]

Florida Statutes) or a state-certified firefighter, prior to April 1, 2012.

Full legal name of employing agency:

____________________________________________________________________________

Employer Representative Full Name and Title

Mailing Address City State Zip

Employer Representative has been authorized by Employer to make the following statement:

__________________________________ was employed prior to April 1, 2012, in the following position:

911 public safety telecommunicator State certified firefighter

Employer Representative Signature: Date:

Applicant’s Name During Employment (if different):

E. PUBLIC RECORDS EXEMPTION

Exemption from public records: Your responses in filling out this form are a public record. That

means that anyone can request a copy of your filled out form. However we will not supply your home

address, telephone numbers, social security number, date of birth, or photograph if you meet an

exemption set forth in Section 119.071, Florida Statutes. If you have questions about this, please review

Section 119.071, Florida Statutes, and in particular, subsection 4 [§119.071(4), F.S.]. Additional

information, including the Government-in-the-Sunshine Manual can be found at http://myfloridalegal.com.

I am an active or former, sworn or civilian member of law enforcement [§119.071(4)(d)2.a.(I), F.S.]

I am a firefighter certified in compliance with § 633.35 [§119.071(4)(d)2.a.(III)b., F.S.]

I qualify under another exemption from the Public Records laws. Identify the exemption and

your basis for qualification for the exemption:

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APPLICATION FEES ARE NOT REFUNDABLE

F. OATH

I, _______________________________ am the person referred to in this application. All statements

contained herein and in any attachments hereto are true, correct and complete; I am free from addiction

to alcohol and I am free from any controlled substance; and, I am free from any physical or mental defect

or disease that might impair my ability to perform my duties consistent with the certification applied for.

PERFORM ONE OF THE FOLLOWING:

(1) Under penalties of perjury, I declare that I have read the foregoing STATEMENT and the facts stated

in it are true.

Signature Date ________________

OR [REQUIRES ADMINISTRATION OF AN OATH UPON YOU BY A PERSON AUTHORIZED TO

ADMINISTER OATHS SUCH AS A NOTARY PUBLIC].

(2) SIGNATURE ________________________________________ DATE ________________

STATE OF

COUNTY OF

Sworn to (or affirmed) and subscribed before me this ______ day of _________________, 20_____,

by (name of person making statement)

.

Signature of Notary Public - State of Florida

______________________________________________________________________

Print, Type, or Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced

Contact Information:

Mailing address for application and fees:

Florida Department of Health

Bureau of EMS/911 PST Program

4052 Bald Cypress Way Bin A-22

Tallahassee, FL 32399-1722

Bureau of EMS/ 911 Public Safety Telecommunicator Program:

Phone: (850) 245-4440

Fax: (850) 488-2512

Website: www.fl-ems.com

E-mail: EMS_Operations@flhealth.gov

Please make certified check, money order, or agency check payable to the Florida Department of Health

No personal checks will be accepted.

Page 4 of 4 DH5066, 01/12

APPLICATION FEES ARE NOT REFUNDABLE

DEFINITIONS

"911 public safety telecommunicator " means a public safety dispatcher or 911 operator whose duties

and responsibilities include:

1. The answering, receiving, transferring, and dispatching functions related to 911 calls;

2. Dispatching law enforcement officers, fire rescue services, emergency medical services, and

other public safety services to the scene of an emergency;

3. Providing real-time information from federal, state, and local crime databases; or

4. Supervising or serving as the command officer to a person or persons having such duties and

responsibilities.

However, the term does not include administrative support personnel, including, but not limited to, those

whose primary duties and responsibilities are in accounting, purchasing, legal, and personnel.

“Employment” means engaged in the service of another for salary or wages subject to withholding,

FICA or other lawful deductions.

“Full Time” means a position that exclusively performs the duties and responsibilities of a 911 public

safety telecommunicator and occupies an entire Full Time Equivalency (FTE) position for the employer.

“Supervised” means overseen during the execution of duties as a 911 emergency dispatcher.

“Supervising or Serving as the Command Officer” means engaging in direct or secondary, but not

tertiary, supervision of one or more 911 emergency dispatchers in their performance of actions 1-3 as

listed in the definition of 911 emergency dispatcher.

“Providing real-time information” means doing so as part of a 24/7/365 program to law enforcement

officers while dispatched to or on the scene of an incident.

*THIS PAGE IS CONFIDENTIAL AND EXEMPT FROM PUBLIC RECORDS

DISCLOSURE AND MUST BE SUBMITTED WITH YOUR APPLICATION*

Florida Department of Health

911 Public Safety Telecommunicator Application

Name:

Last First Middle

Social Security Number:

*This page is exempt from public records disclosure. The Department of Health is

required and authorized to collect Social Security Numbers relating to applications for

professional licensure pursuant to Title 42 USCS § 666(a)(13).

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Fillable 911 Public Safety Telecommunicator Initial/Original Certificate Application This (Florida Department of Health)

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