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SC DHEC Division of EMS Trauma Certification Application Form SSN Last 4 s SC State Certification Number National Registry Certification Number SC Level of Certification Check One EMT PARAMEDIC I-85/AEMT Last Name First Name E-Mail Address Date of Birth mm/dd/yyyy City State Zip Code Cell Phone Number Including Area Code Home Phone Number Including Area Code Attach the Following Credentials Out of State Credential or Attach a copy of your current Out of State or NREMT Credential BLS CPR Credential BLS card MUST be one of the following AHA BLS for the Healthcare Professional ARC CPR for the Professional Rescuer ASHI CPR Pro Additional Credential for Paramedics SC State Criminal Background Check Advanced Cardiac Life Support ACLS Credential fingerprint receipt ACLS credential MUST be one of the following You may call IBT at 866-254-2366 to make an appointment AHA ACLS ASHI ACLS SC DHEC EMS ORI SC920111Z I hereby affirm that all statements on this form are true and correct including the copies of all cards certifications and attachments. It is understood that false statements or documents may be sufficient cause for denial/revocation of my EMT credential by SC DHEC. It is also understood that SC DHEC may conduct a full audit of all activities listed on this form at any time. Your Signature Must be original signature Date Signed DHEC 2351 09/2011 SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL. It is understood that false statements or documents may be sufficient cause for denial/revocation of my EMT credential by SC DHEC. It is also understood that SC DHEC may conduct a full audit of all activities listed on this form at any time. It is also understood that SC DHEC may conduct a full audit of all activities listed on this form at any time. Your Signature Must be original signature Date Signed DHEC 2351 09/2011 SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL. It is understood that false statements or documents may be sufficient cause for denial/revocation of my EMT credential by SC DHEC. It is also understood that SC DHEC may conduct a full audit of all activities listed on this form at any time. Your Signature Must be original signature Date Signed DHEC 2351 09/2011 SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL.

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