Registration for Emergency Medical Technicians’ Exam
Test Scheduling Request
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services & Trauma Systems
Please Print
BEMS USE ONLY:
Name
First Name MI Last Name
Address
Street APT. #
City State Zip Code
Scheduled for: Site #:
Address Change Email Address
Exam Level: CFR EMT A-EMT Critical Care Paramedic Instructor CIC CLI
Student ID #: ____ ____ ____ ____ ____ ____ – ____ – ____ ____ ____ ____ ____ ____ (Get from your instructor or exam ticket)
(Course Number) (EMT Number)
Date of Birth:
/ /
Student’s Phone Number:
( ) –
Month Day Year Daytime Number
Selected Test Date:
/ /
Time: 7:00 p.m. My Original Test Date:
/ /
Month Day Year Month Day Year
Please Choose Between One of the Following Test Sites
Regional Test Site (RTS) Location: (Refer to RTS list on our web site. Select a site and indicate site number here).
It will take approximately 4 weeks to get your test score in the mail.
There is no charge.
Students who have received prior approval for an ADA accommodation may be tested at a Regional Test Site. Please make sure that you
notify us that you have already requested an accommodation.
– OR –
On-Site Scoring Test Site Location: (Not available for CFR Level)
Please refer to the OSS list.
OSS Number
Select the site you wish to register for and place the number of that site in the box to the right.
There is a fee of $20.00 payable to PSI in the form of money order or certified check. No cash, credit cards or personal checks will be
accepted. Payment is to be made at the examination site.
There is NO on-site scoring examination available for CFR Level.
We are not able to test students requiring an ADA accommodation at on-site scoring locations.
Student’s Signature: Date:
/ /
Month Day Year
IMPORTANT!
Requests for test scheduling are due to the Bureau of Emergency Medical Services no later than eight weeks before the scheduled
examination date. For exam testing dates and testing locations, please refer to www.health.ny.gov/professionals/ems/certification. There is
limited seating at most locations and registrations are taken on a “first come, first serve” basis. If you do not receive your exam confirmation
by email within three weeks of the scheduled exam date, please notify the office immediately.
NEW ADDRESS
As of April 1, 2019, test scheduling requests will only be accepted by email.
Scan completed form and email to ems.test.request@health.ny.gov
SUBMIT
PLEASE NOTE: FAX SUBMISSIONS WILL NO LONGER BE ACCEPTED
If you are registering for an exam and you have a failure letter from on-site scoring, you must include the letter with this form.
DOH-4245 (3/19)
