Fillable Verification of NYS Certification (New York State)

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Verification of NYS Certification (New York State)

On average this form takes 35 minutes to complete

The Verification of NYS Certification (New York State) form is 1 page long and contains:

  • 1 signature
  • 2 check-boxes
  • 137 other fields

Country of origin: US
File type: PDF

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NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Emergency Medical Services and Trauma Systems
Verification of NYS Certification
EMS Identification Number
Only write your NYS EMS number in this space
Last Name
First Name and M.I.
Social Security Number Month Day Year
Date of Birth
Certified Provider’s Mailing
Street Address
Apartment Number
City
State Zip Code Name or address change since you last became certified?:
Yes No
If you require that your letter of verification be e-mailed to a different e-mail address, please provide the e-mail address to
which the letter should be sent:
(Certified Provider’s Signature)
(Date)
Please print legibly in capital letters or type. Put one letter or number in each box.
A letter of verification will be e-mailed to the e-mail address from which this form is submitted.
Requests for verification of certification must be submitted using this form.
No telephone requests will be accepted. Allow 2-4 weeks for processing.
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Verification of NYS Certification (New York State)

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Completed 19 July 2021

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