Any moving violation (not for paperwork offenses such as inspection/registration or defective equipment) Valid Texas Drivers License CDL Holders are not eligible Valid Texas Auto Liability Insurance.OFFENSES
EXCLUDED Offenses in construction zones when workers are present Speeding 25 miles or more over the speed limit
95 miles per hour or more
Passing a School Bus
appearance in court)LENGTH OF PROBATION90 Days (Three months)30-180 Days EXTRA EXPENSES$10.00 to Department of Public Safety $25-$100 for certified driver safety course Drivers who hold provisional licenses must pay $10 to Department of Public Safety for examination fee (Effective 9/1/2005)
Drivers under age 25 must pay $25-100 for driving safety course (Effective 9/1/2005)
CONDITIONS OF 1.No moving violations during period of probation
2.Obtain Driving Record from DPS
3.Take driving safety course
4.Provide court with Driving Record and certificate of course completion before end of probation
No moving violations during period of probation
Return affidavit of compliance
Drivers under age 25 must complete a driving safety course approved under Chapter 1001, Education Code (Effective 9/1/2005)
Drivers who hold provisional licenses must be examined by the Department of Public Safety (Effective 9/1/2005)
Proof of course and examination completion must be provided to the court FOR NON - COMPLIANCE1.Conviction
2.Payment of Additional Fine
3.Offense reported to DPS
Potential warrant for arrest if fine remains unpaid
2.Bond forfeited to Fine
3.Offense reported to DPS.
An Equal Employment Opportunity Employer
Regulatory Licensing Unit EMS Certification & Licensing Group
EMS Personnel Rec A RENEWAL ONLY
See attached Privacy Notice.
All information given on this application is considered
public record, with the exception of social security number* and driver license number.
Electronic application & fee submission available APPLICATION SUBMISSION:
Expect application processing to take a 3 weeks.
Check your a status you are required to pass exam, see Testing Instruction in Section 5, Option 1.
Submit application including fee payment, if not exempt, and required
Documentation (if directed in Section 5) to
Additional information 1 Personnel Data
TYPE OR PRINT IN BLACK > ______________________ Print Last Name First Name Middle Name ocial Security Mailing Address:
Street, Apt Number or PO Box City State Zip > (_______)__________________ Home Phone (area code)
Business Phone (area code) Date of Birth (MM/DD/YY) Driver License Number (include Alternate
Street, Apt number or PO Box City State Zip ** This may be desired by candidates whose employer mandates the business address as the mailing address.
Disciplinary action proposals will be sent to both the mailing address and the alternate address.Certificates/licenses and renewal notices will only be sent to the mailing address.* Disclosure of your social security number is mandatory under Family Code, Chapter 232
Section 2 Volunteer Sign- Complete if applicable If you are claiming fee exempt status, this section should be completed by approved EMS Provider or FRO administrator.This candidate is exempt from the payment of fees because he/she actively provides emergency medical care for our organization, and does not receive compensation*** for providing these services.
Additionally, to the best of my knowledge, this candidate does not provide emergency care for any organization, in return for compensation***, other than reimbursement as described below.
I have explained to the candidate that if during the certification period, they begin to receive compensation*** for providing emergency medical services from any organization, the exemption is inapplicable and they are required to send a prorated fee to the department. Signature of provider or FRO administrator Print signed name ***Compensation does not include reimbursement for actual expenses for medical supplies, gasoline, clothing, meals and insurance incurred while volunteering.Provider or FRO name: City:
D license or registration number: Phone:
Section 3 Application Level Check the appropriate box.
Mark the level for which you are applying:
ECA o EMT o EMT-Intermediate o Paramedic
This application is not for License Paramedic renewal.
Licensure application is available on our web site.
For DSHS Use Only ZZ100 Receipt # ____________________ Date ____________________ Dept of State Health Serv Attn:
ZZ100-160 EMS 1100 West 49th St.Austin, TX
78756-99 > ______________________ Print Last Name First Name Middle Name ocial Security number*
Section 4 Criminal/Disciplinary History Everyone must answer Yes or No to questions A & B
Failure to report any limitation, suspension and revocation of a license and/or any conviction(s) and/or deferred adjudication case information may result in disciplinary action and/or denial/decertification against your Texas EMS personnel certification or licensure.
If you previously submitted court documentation with another Texas EMS application,
there is no need to resubmit that documentation .
You must attach documentation for any new offense/conviction related to a misdemeanor, felony or deferred adjudication, or for any license suspension or revocation since your last EMS application submission.A.
Have you ever been subject to limitation, suspension, or revocation of a license, including your right to practice in a healthcare occupation, voluntarily surrendered a license in any state or to a state agency that had issued you a license, or were denied a license? o Yes
o No If you answered yes to question A above, provide the date of action, state and agency name, action taken and case number;
you may provide an explanation on an attached page.B.
Have you ever been given deferred adjudication or been convicted of a felony or misdemeanor?
o No DO NOT answer Yes if you only have minor traffic violations, e.g.
speeding tickets or minor parking violations. If you answered yes to question B above, provide the following information below.C.
Indicate offense(s) committed & court case/cause number(s): D
Date(s) of conviction(s) and/or deferred adjudication(s): ): ): ___________
City, County and State where offense(s) F.
List other names you have used (e.g.alias, married/maiden, etc.): Section 5
Application Type Check appropriate box(es).In ALL cases, certification does NOT extend past your expiration date.
Apply for recertification no earlier than one year prior to your expiration date.o
Option 1/Written Assessment Exam If you do not pass the exam, retesting is available, but you may not gain renewal by choosing
another option nor may you apply for inactive status. - Schedule your exam AFTER
- Schedule exam on state web site at: - Submit NR fee at test site application & fee processing http://www. - Volunteers NOT exempt from NR fee - Check test eligibility at: - In addition to state fee, you owe NR fee
- NR fee payable by mone
Page 6 of 6
10/20/2010 EMS COMPLIANCE AND QUALITY ASSURANCE DEPARTMENT OF STATE HEALTH SERVICESThis document is your FAST Fingerprint Pass for a state and national criminal history record check.
Please schedule a fingerprint appointment by visiting www.L1enrollment.com or by calling 1--2080.
When scheduling an appointment you will be prompted by L-1 Enrollment Services for the following additional personal data: Date of Birth, Sex, Race, Ethnicity, Skin Tone, Height, Weight, Eye Color, Hair Color, Place of Birth and Home Address.During your Fingerprint appointment you will also be prompted for Social Security Number and Driver License Number.Requested data is required by the Texas Department of Public Safety to process your background check.
These data elements have been omitted from this document in order to better protect the security of your personal information.You may pay for FAST services online with a credit card or onsite with a check or money
Your fingerprints will be submitted to the Texas Department of Public Safety and the Federal Bureau of Investigation.
Logon to : Texas Select: Online Scheduling Select: English or Espanol Select: All Others Enter: First and Last Name Select: Option A
Electronic Submission Select: Yes, I have a FAST Fingerprint Pass Enter: TX920390Z Follow the prompts to enter requested information.Bring this completed form with you to your appointment.Section One: Qualified Entity > (If resubmission for rejected fingerprints)Application Type_Initial or Renewal
EMS Name: _Department of State Health Services
EMS Two: Applicant Name (To be completed by applicant) t: : : print) (Please print)
Section Three: Waiver Information (To be completed and signed by applicant) I certify that all information I provided in relation to this criminal history record check is true and accuratI authorize the Texas Department of Public Safety (DPS) to access Texas and Federal criminal history record information that pertains to me and disseminate that information to the designated Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, through the DPS Fingerprint-based Applicant Clearinghouse of Texas and as authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute or policy.
I authorize the Texas Department of Public Safety to submit my fingerprints and other application information to the FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to tapplication.I authorize the FBI to disclose potentially pertinent information to the DPS during the processing of this application and foas long hereafter as may be relevant to the activity for which this application is being submitted.
I understand that the FBI may also ion, where all such data will be subject to comparisons against other submissions received by the FBI and to further disseminations by the FBI as may be authorized under the Federal Privacy Act (5USC 552a(b)).
I understand I am entitled to obtain a copy of any criminal history record check and challenge the accuracy and completeness of the information before a final determination is made by the Qualified Entity.
I also understand the Qualified Entity may deny me access to children, the elderly, or individuals with disabilities until the criminal history record check is completed.Signature: > Date: Four: Service Center Information (To be completed by FAST Enrollment Officer) Date Prints Taken _______________________ Amount Charged For Service: _$44.20
Paid by: Check Money Order Visa MasterCard Billing : I HAVE COMPARED THE GOVERNMENT-ISSUED IDENTIFICATION PRESENTED BY THE APPLICANT AND ATTEST THAT TO MY BEST DETERMINATION; I HAVE FINGERPRINTED THE SAME PERSON.
Signature: print) Texas Department of State Health ServicesEMS Certification & Licensing GroupCash Receipts Branch, MC 2003P.O.Box 149347Austin, Texas 787149347(512) 8346700 FAX (512) 8346714 Reciprocity Verification Form A YOU MUST SUBMIT THIS FORM TO EVERY STATE EVER HELD CERTIFICATION IN.> _______________________ ___________________Applicants Last Name, First Name
Social Security number Certificate/License numberCHECK HERE IF YOU RECEIVED YOUR EMS TRAINING IN THE MILITARY, AND PROVIDE DOCUMENTATION.State officials ONLY : Please complete the following and return by mail or fax.Level of Certification: Issuance Date: Expiration course taught in conformance with the U.S.Department of Transportation (DOT) Standards for: Emergency Medical Technician (EMT) 1994 curriculumYes EMTIntermediatecurriculumYes EMTParamedic (EMTP):
most recent training: Type of
recent For EMTIntermediate 1985 curriculumONLY:
If the applicant has EMTIntermediate (EMTI) certification please check which skills were included in the applicant's certification course (please note, Texas recognizesEMTI certification only if , EGTA, PTL or ETC **< boxes are checked[** We will accept any of these alternative airway devices:
esophageal obturator airway, esophageal gastric tube airway, pharyngotracheal lumen airway, combination esophagealtracheal tube (Combitube)] To the best of your knowledge, has the applicant ever been convicted of a felony or misdemeanor?Yes
Has your state/entity ever taken disciplinary action against this individual's EMS personnel certification?Yes
Does your state run Criminal History checks?Yes
If so, has this person ever answered yes or disclosed a Criminal History?Yes
(If Yes to any question, please provide supplemental information on a separate sheet) Has your state/entity ever granted reciproc
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