Nevada Emergency Medical Systems Program
4150 Technology Way, Suite 101 ● Carson City, Nevada 89706
775-687-7590 ● Fax 775-687-7595 ● http://dpbh.nv.gov/Reg/EMS/EMS-home/
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VERIFICATION OF EMS LICENSE/CERTIFICATION FORM
Applicant- Complete the top portion of this form and forward it to each state or territory (not applicable to the National
R
egistry) where you have been licensed, certified, or registered as an emergency medical services provider (make copies as
necessary).
Section 1: Applicant information
Last Name: ____________________________ First Name: ____________________________ MI: ____
Address: ___________________________________ City/State/Zip: _____________________________
Original License/Certification number ____________________
Date issued: ______________________________ (in the state to which the form is being forwarded)
Type: ___ Emergency Medical Technician ___ Advanced Emergency Medical Technician ___Paramedic
Signature______________________________________________ Date: __________
TO BE COMPLETED BY VERIFYING AGENCY ONLY
Section 2: Verifying Organization: Please complete this section as fully as possible. The information you provide
determine this individual’s eligibility for Nevada EMS certification.
I certify that the above-named individual was issued license/certificate number: __________________
Effective Date: _________________________ Expiration Date: ________________________
Does your agency currently require successful completion of a training program adhering to the United States Department
of Transportation, National Highway Traffic Safety Administration National Standard Curriculum? ____YES ___ NO. If
no, please provide a brief description of the requirements this individual completed for purposes of certification. (Separate
document)
Has this individual ever been subject to disciplinary action of any type or is this individual currently the subject of a
pending disciplinary action or unresolved complaint? ___ YES ___ NO.
If yes, please forward all publicly disclosable information regarding the individual’s status and the basis for same.
Name: ___________________________________ Signature:___________________________________
Title: ___________________________ Name of Agency: ______________________________________
Address: _____________________________________________
City/State/Zip: __________________________________
Telephone Number: _____________________
Email: ______________________________
Completed verification forms can be sent to the Nevada EMS Program by email: HealthEMS@health.nv.gov or fax: (775)
687-7595.
Verifying State
Seal
