ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY
EMT-I Certification Application
More information about the certification process can be found on the back of this application
Tab through the field to complete. Print two copies of this form, one to submit and one for your records
Name: SS#: - -
Address: D.O.B.: / /
City: State: Zip: Phone: [ ] -
CA Drivers License #:
Yes No ELIGIBILITY REQUIREMENTS
Press the ‘enter’ key to select yes or no
Are you at least 18 years old?
Have you ever been denied EMT certification, had an EMT certificate suspended or revoked, or are you under investigation by this
or any other agency? If yes, please attach a letter of explanation.
Are you currently under investigation or have you ever been arrested and convicted of an infraction, misdemeanor, or felony in
California or in any other state or place, including entering a plea of nolo contendere or no contest, and including any conviction
which has been expunged (set aside) or have records sealed under Penal Code Section 1203.4? If you checked "Yes", refer to the
instructions in the Background Check Information section on the back of this form.
Have you completed a ONE TIME Department of Justice Live Scan background check for Alameda County EMS? Your Live Scan
also provides the EMS office with ongoing information of any subsequent arrests. Only employees of Alameda County Public
Safety agencies who had a background check as part of the hiring process are exempt from this requirement.
Are you currently certified in AED and CPR including adult and pediatric BLS? Certification must be equivalent to the American
Heart Association‘s Healthcare Provider level.
Have you passed the NREMT written exam? NREMT number: .
(check one) INITIAL CERTIFICATION or CHALLENGE EXAM (explanation on the back of this form)
Course completion date:
City: State: Zip:
I understand that all the information on this application is subject to verification. I certify, under penalty of perjury, that the information provided
is true and correct and that any fraudulent entry may be considered a sufficient cause for rejection or subsequent revocation.
Signature: ___________________________________________________________________________________________ Date: / /
Complete, sign, and date the application?
Attach a copy of your course completion certificate?
Attach a copy of your NREMT card?
Attach a copy of the front and back of your signed CPR card?
Attach a copy of a photo ID: current driver’s license, ID card, or valid military ID card?
Complete a Department of Justice Live Scan background check and attach a copy of the form?
(Employees of Alameda County Public Safety agencies who had a background check as part of the hiring process are exempt from this requirement.
If this applies to you, please attach a copy of your ID card).
Enclose the $35.00 non-refundable application fee? We do not accept personal checks or cash. Make your money order, cashier’s check, or
municipal purchase order payable to Alameda County EMS Agency and sign it.
Mail or take the complete package to Alameda County EMS, 1000 San Leandro Blvd, Suite 200, San Leandro, CA 94577
October 25, 2007
EMT applications are processed once per week. Allow a minimum of two weeks to receive your new card.
NREMT Written Exam:
The National Registry Emergency Medical Technician (NREMT) Basic Examination is the Alameda County EMS approved exam. The NREMT
computer-based exam is scheduled through http://www.nremt.org.
Background Check Information:
If you are currently under investigation or have ever been arrested and convicted of an infraction, misdemeanor, or felony in California or in
any other state or place, including entering a plea of nolo contendere or no contest, and including any conviction which has been expunged (set
aside) or have records sealed under Penal Code Section 1203.4 please attach copies of the final court disposition, and a detailed statement
describing the crime(s), date, location, court, sentence served, and parole if any. These documents will help us determine whether you can
be certified as an EMT under Alameda County EMS Policy #3203, Health and Safety Code section 1798.200, and the state’s Emergency
Medical Services Authority. Failure to include this documentation will delay the processing of your application and failure to disclose this
background information may result in denial of an EMT certificate. Your Live Scan also provides the EMS office with ongoing information of
any subsequent arrests.
For Further Information: - Go to http://acgov.org/ems then click on the EMT Certification button. Information includes:
A link to view our EMT Certification Policy.
A link to fill out and print the EMT Certification Application.
A link to view instruction to complete your Background Check and Live Scan application from the Background Check Information
A link to fill out and print copies of the Live Scan Application. Print two copies, one for the agency doing the Live Scan and one for
EMS. If you want a copy for your files, print three copies.
A link to view a list of locations where you can get your Live Scan done.
A link to view our Background Check Policy.
A link to view a list of Frequently Asked Questions about certification, what happens after I have my EMT card, recertification, CPR
classes, and more.
Who can take the Challenge Exam?
Only a currently licensed physician, registered nurse, physician assistant, vocational nurse, currently EMT-P, or an individual with
documented evidence of successfully completing an EMT training program of the Armed Forces as defined in Title 22, Division 9, Chapter
2, section 100078 is eligible to take a challenge exam. Contact the EMS office if you are a challenge candidate.
[for EMS Agency use only]
_______________ Application received _______________ Course completion date _______________ Certification number
_______________ Payment received _______________ NREMT Number _______________ Approved by
_______________ Roster received _______________ Effective date _______________ Date mailed
_______________ SID# _______________ Expiration date
October 25, 2007