INSTRUCTIONS: Complete one list for each vehicle you
are sending.
Corps Name: Ambulance or Fly Car ID you will be sending:
NYS EMS (4 digit) Agency ID Code: NYS
License Plate on above vehicle:
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Last Name |
First Name |
MI |
Social
Security No. |
EMT
Level |
NYS EMT # |
EMT
Expiration Date |
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2 |
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3 |
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4 |
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5 |
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6 |
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This form must be completed and faxed to Mike McEvoy, EMS-1
at 383-4915 as soon as possible. You
may also email the form as a Word Document to McEvoyMike@aol.com if you choose.