CITY OF NEW ORLEANS EMT PERMIT APPLICATION
EMS DIVISION
2929 Earhart Blvd., New Orleans, LA 70125
(504-658-2732 or rbenelli@nola.gov)
This application must be completed in its entirety; money order for permit must accompany application.
Last Name: First Name: M.I.
Home address Apt. No.
City:
State:
Zip Code:
Date of Birth:
Driver's License #: Class:
Primary EMS Employer:
Are you addicted to either of the following: Alcohol
Yes
No
Drugs
Yes No
The following materials must be submitted with this application. Fraudulent copies will result in permit being revoked.
1. Current National Registry Certification Card
2. Current Louisiana Driver's License - Class D
3. State of Louisiana EMT Permit
4. Defensive Driving Certification - must not expire within 30 days of date of application
5. CPR Certification - must not expire within 30 days of date of application
6. ACLS Certification - must not expire within 30 days of date of application (Paramedics Only)
7. Annual Permit Fee of $35 by
money order only - payable to the City of New Orleans
A late fee of $100.00 will be assessed if the application is not submitted in its entirety prior to the expiration date or if the
applicant fails to provide the City of New Orleans with updated copies of expired certifications. A fee of $150.00 will be
assessed to all applicants who allow their LA State EMT License to lapse or their Orleans Parish Permit to be revoked.
I, the undersigned, agree to follow the current Orleans Parish Medical Society Protocols when working in Orleans Parish. I
authorize the City of New Orleans to investigate the validity of all statements and/or information provided on this
application.
Signature:
OFFICE USE ONLY
Application Fee: _________________ Money Order#:_____________________
Late Fee:________________________
Revocation Fee:__________________
Processed By:_________________________________________ Date:_____________________________
Date:
NOEMS
WEBSITE
Phone No.:
Email Address:
PERMIT APPLICATION WILL ONLY BE PROCESSED VIA MAIL
National Reg. Exp. Date: State Exp. Date: CPR Exp. Date:
ACLS Exp. Date:
Driver's License Exp. Date:
Defensive Driving Exp. Date:
Maiden Name (if applicable):
National Reg. #: State EMT #:
Check One:
New
Renewal
