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The C 08 B Georgia form serves as a crucial document for individuals seeking out-of-state licensure as Emergency Medical Technicians (EMTs) in Georgia. This application is designed for those who hold current certifications from other states and wish to practice within Georgia’s borders. A non-refundable fee accompanies the application, with amounts varying based on the level of certification—$75 for Basic, $85 for Intermediate, and $150 for Paramedic applicants who have lapsed certification for over two years. Applicants must provide personal information, including their legal name, Social Security number, and contact details. Additionally, the form requires documentation of current CPR credentials, proof of completion of a state-approved course, and a copy of the National Registry of Emergency Medical Technicians (NREMT) wallet card. Background disclosures are also necessary, asking applicants to disclose any criminal history, previous license denials, or employment issues. The form ensures that applicants are thoroughly vetted, which includes an investigation into their moral character and professional reputation. By submitting this application, individuals commit to upholding the standards of the Georgia Department of Public Health while serving the community as EMS professionals.

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GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

EMS OUT-OF-STATE LICENSURE APPLICATION GEORGIA STATE OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA Form C-08-B

APPLICATION – PRINT IN INK OR TYPE

 

Initial EMT Certification Fee - $75*:

 

BASIC

Mail application

State Office of EMS and Trauma

 

Reinstatement Certification Fee

 

INTERMEDIATE 85

and required

ATTN: Personnel Licensure

 

 

 

 

documents to:

2600 Skyland Drive - Lower Level

 

Lapse 2yr of Certification - $150*

 

PARAMEDIC

 

 

 

 

 

Atlanta, GA 30319

 

 

 

 

 

* The non-refundable fee must accompany this application. Payment must be in the form of Money Order, Business Check

or Cashier's Check Only. MAKE ALL FEES PAYABLE TO "GEORGIA DEPARTMENT OF PUBLIC HEALTH"

PERSONAL INFORMATION

Legal Name

 

 

 

 

 

SSN _______ - _____ - __________

 

Last

First

M.I.

 

 

 

Address

 

 

 

 

 

Birth Date

______ - _______ - _________

City

 

 

County _______________

State

 

Zipcode ___________

Phone (______) _______ - __________ E-Mail ____________________________________________________

CERTIFICATION REQUIREMENTS - Applicant shall provide all listed information and/or documents

 

 

Documentation attesting to current CPR credentials

 

 

Proof of completion of a state approved course

 

 

Copy of current NREMT Wallet Card

 

 

Copy of your Federal or State Government

 

 

 

 

 

 

NREMT Registry #

_________________________

 

 

Issued Photo Identification

 

 

 

Current NATIONAL CRIMINAL HISTORY REPORT generated

 

EMT-Paramedic Applicants: Documentation

 

 

 

 

 

no earlier than twelve (12) months prior to submitting an

 

 

attesting to current ACLS credentials.

 

 

 

 

 

 

 

 

application for licensure that includes your name, birthdate and

 

For ATP Applicants ONLY:

 

 

 

at least part of your SSN. Internet searches meeting the above

 

Passed Advanced Tactical Practitioner written

 

 

 

 

 

 

 

 

criteria are accepted.

 

 

 

exam and hold current credentials.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERIFICATIONS

 

 

 

 

 

 

► Do you hold any other license(s) or certificate(s)?

 

 

__ Yes

__ No

 

Kind of Certificate/License and State of Issuance

Certificate/License Number

Date Issued

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

BACKGROUND DISCLOSURE

► Have you ever been arrested and/or convicted of any National, Federal, State or Local felony and/or

misdemeanor offense in Georgia or in any other state or place?

__ Yes

__ No

► Are there any criminal charges pending against you?

__ Yes

__ No

If you answered yes to either of the above questions, attach a detailed written statement, signed and dated, describing the crime(s), date, location, court, sentence served, and parole, if any. Attach copies of all related records, court documents and police reports.

► Have you ever been denied the privilege of taking an examination given by any state licensing board

or been denied a certificate or license?__ Yes __ No ► Have you ever resigned from any employment after a complaint or peer review action has been initiated

against you?

__ Yes

__ No

► Have you ever voluntarily surrendered a certificate or license for any reason?

__ Yes

__ No

► Have you ever had a certification, accreditation or professional healing arts license suspended, revoked

or placed on probation; and/or are you currently under investigation?__ Yes __ No

If you answered yes, attach a detailed written statement, signed and dated, describing the event, investigation, action, any corrective action, and/or remediation as a result of the action.

All applications are processed within 5-7 business days from the date received. Congratulations! Your willingness to serve Georgia’s citizens as an EMS professional is appreciated!

GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

GEORGIA OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA

AFFIDAVIT OF APPLICANT

I acknowledge and state that I have read and answered all questions in compliance with this application. I acknowledge that it is my responsibility to read and become familiar with the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services 111-9-2.

I further state that by filing this application for a license in the State of Georgia, I hereby authorize and consent to have an investigation made as to my moral character, professional reputation and fitness for practice as an EMS provider. I agree to give any further information which may be required in reference to my past record. I understand that I will not receive a copy of the report or know its contents and I further understand that the content of the investigative report will be privileged, unless determined otherwise by the Board or Court Order.

I hereby release, discharge, and exonerate the Georgia Department of Public Health, its agents, representatives, and any person so furnishing information, from any and all liability of every nature and kind arise out of the furnishing or inspection of such documents, records or other information or the investigation made by the Georgia Department of Public Health. I authorize the Georgia Department of Public Health to release information, material, documents, orders of the like relating to me or to this application to any other agency of the State of Georgia, the licensing agency of any other State or Territory of the United States or Province of Canada, a law enforcement agency, a hospital, or other agencies determined by the Board.

This is to certify that the foregoing information is true and correct to the best of my knowledge. I understand that any person who shall give false or forged evidence of any kind to the Board may be prosecuted to the fullest extent allowed by law.

Signature of Applicant

 

Date

 

 

 

 

 

Name Of Applicant

 

City

State

Being duly sworn, says that he/she is the person who executed this application for licensure as an EMS provider in the State of Georgia; and that all the statements herein contained are true in every respect and that the attached photo is a true photo of applicant.

Sworn to and subscribed before me this ______ day of ___________, 20_____.

____________________________________________________

Notary Public

My Commission Expires _______________________________

(SEAL)

Attach Photo Here

Notary: DO NOT notarize this section unless a passport photograph is attached.

FORM C-08-B: OUT-OF-STATE APPLICATION FOR LICENSE

Verifying Person’s Name: _____________________________________
Agency Name: ______________________________________________
Phone Number: ____________________________ Ext: ___________
DO NOT WRITE BELOW THIS LINE
(For OEMS Use Only)

GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

GEORGIA OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA

LICENSE VERIFICATION FORM

This form is used to verify the good standing of EMT or paramedic license or certification applicants who are licensed or certified by another state. Please note that you must submit a separate form for each license and/or certification you hold. Your application cannot be processed without this form.

PART I: Completed by Applicant

Legal Name: _______________________________________________ SSN: ______ - ______ - __________

Current Address: ______________________________________________________________________________

______________________________________________________________________________

I am requesting Georgia license based on the following current license(s) or certification(s):

___ in the state of __________________ AND by the National Registry of EMTs

Current certification(s) or license(s) in another state or issued by the National Registry of EMTs:

EMT - Basic Certificate

# ______________

Expiration Date

____________________

EMT - Intermediate Certificate

# ______________

Expiration Date

____________________

Paramedic Certificate

#

______________

Expiration Date

____________________

Other (specify) ______________________________________

 

 

Certificate

#

______________

Expiration Date

____________________

PART II: Completed by the State Certifying Agency

Please assist by verifying that this individual is currently certified and in good standing according to your certification policies.

A. Is the above-referenced cited certificates(s) or license(s) deemed current and valid according to your

policy?

__ Yes

__ No

B. Has the above certification(s) or license(s) ever been revoked or suspended?

__ Yes

__ No

If yes, please explain ______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

C.

Has the above listed individual ever been convicted of a felony?

__ Yes

__ No

 

If yes, what was the offense? _______________________________________________________________

 

Date of conviction ______________________ Place of conviction ________________________________

D.

Do you know of any reason licensure in Georgia should be denied?

__ Yes

__ No

 

If yes, please explain ______________________________________________________________________

__________________________________________________________________________________________

Title: _________________________

State: _________________________

Date: _________________________

Application Documents

Application Complete

Government Photo ID

Course Completion

NREMT Card

CPR Credentials

Nat'l Criminal Background

Other Certifications

(ATP, ACLS, ETC)

Application Fee

Type: __ M/O __ C/C __ B/C

CH # ________________________

Date: ____/_____/20______

Amount Recv'd: $ _____________

Recv'd by: __________________

 

Certification Status

Status: __ Approved __ Denied

Date:

____/_____/20______

License #

___________________

Exp Date:

____/_____/20______

Notes: ____________________________

___________________________________

___________________________________

Form Specifications

Fact Name Description
Form Purpose This form is used for applying for out-of-state licensure as an Emergency Medical Technician (EMT) in Georgia.
Application Fees Initial EMT certification fee is $75 for Basic, $85 for Intermediate, and $150 for Paramedic. Fees are non-refundable.
Payment Methods Payments must be made via Money Order, Business Check, or Cashier's Check only, payable to the Georgia Department of Public Health.
Certification Requirements Applicants must provide documentation for CPR credentials, a state-approved course, and a current NREMT wallet card, among other requirements.
Background Disclosure Applicants must disclose any arrests, convictions, or pending criminal charges. Detailed statements and documentation are required if applicable.
Processing Time All applications are processed within 5-7 business days from the date received.
Governing Law The application is governed by the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services (Rule 111-9-2).

C 08 B Georgia: Usage Guidelines

Filling out the C 08 B Georgia form is an important step in applying for out-of-state licensure as an EMS provider. After completing the form, you will need to submit it along with the required fees and documentation to the Georgia State Office of Emergency Medical Services and Trauma. Be sure to follow the instructions carefully to ensure your application is processed smoothly.

  1. Personal Information: Fill in your legal name, Social Security Number (SSN), address, birth date, city, county, state, zip code, phone number, and email address.
  2. Certification Requirements: Provide documentation for CPR credentials, proof of course completion, a copy of your NREMT wallet card, and your NREMT registry number. Include a government-issued photo ID and a national criminal history report.
  3. Certifications: Indicate if you hold any other licenses or certificates by checking "Yes" or "No." If yes, provide details about the type of certificate/license, state of issuance, and certificate/license number.
  4. Background Disclosure: Answer the questions regarding any arrests, convictions, or employment issues. If you answer "Yes" to any question, attach a detailed written statement and relevant documents.
  5. Affidavit of Applicant: Read the statement and sign the application, certifying that all information is true and correct. Include the date and your printed name.
  6. Notary Section: A notary public must witness your signature. Do not have this section notarized unless you have attached a passport photograph.
  7. Payment: Prepare a money order, business check, or cashier's check for the application fee. Make it payable to "Georgia Department of Public Health." Include the payment with your application.
  8. Submission: Mail the completed application, required documents, and payment to the Georgia State Office of EMS and Trauma at the provided address.

Your Questions, Answered

What is the C 08 B Georgia form used for?

The C 08 B form is an application for out-of-state licensure for Emergency Medical Technicians (EMTs) in Georgia. It is specifically designed for individuals seeking to obtain licensure in Georgia based on their existing certifications from other states.

What are the fees associated with the C 08 B form?

The application fee varies depending on the level of certification. For initial EMT certification, the fee is $75. If you are applying for reinstatement after a lapse of two years or more, the fee is $150. Payment must be made via Money Order, Business Check, or Cashier's Check, and all fees are non-refundable.

What documents do I need to submit with the C 08 B form?

Applicants must provide several documents, including proof of current CPR credentials, a copy of the National Registry of EMTs (NREMT) wallet card, a government-issued photo ID, and a current national criminal history report. Additional documentation may be required based on your specific certification level.

How long does it take to process the application?

Once the application is received, it typically takes 5-7 business days to process. Ensure that all required documents are submitted to avoid delays.

What if I have a criminal history?

If you have been arrested or convicted of any felony or misdemeanor, you must disclose this information on the application. A detailed written statement explaining the circumstances, along with relevant court documents, must be attached. This transparency is crucial for your application to be considered.

Can I apply if my certification has lapsed?

Yes, you can apply if your certification has lapsed, but you will need to pay the higher reinstatement fee of $150. Additionally, you must meet all other certification requirements outlined in the application.

What happens if my application is denied?

If your application is denied, you will receive a notification explaining the reasons for the denial. You may be able to address the issues raised and reapply, but it's essential to understand the specific reasons for the denial before proceeding.

Do I need to notarize the application?

Yes, the application requires notarization. However, do not notarize the application until you have attached a passport-sized photo. This step is necessary for the application to be valid.

Where do I send my completed application?

Completed applications should be mailed to the State Office of EMS and Trauma at 2600 Skyland Drive, Lower Level, Atlanta, GA 30319. Ensure that all required documents and payment are included to facilitate processing.

Common mistakes

  1. Inaccurate Personal Information: Providing incorrect details such as your name, address, or Social Security Number can lead to delays or rejection of your application.

  2. Missing Required Documents: Failing to include necessary documents like your CPR credentials or NREMT wallet card will result in an incomplete application.

  3. Incorrect Payment Method: Submitting payment in forms other than a Money Order, Business Check, or Cashier's Check will cause your application to be returned.

  4. Neglecting Background Disclosure: Not fully disclosing any criminal history or pending charges, when applicable, can lead to serious consequences and potential denial of your application.

  5. Omitting Signature or Date: Failing to sign and date the application can render it invalid and delay the processing time.

  6. Inadequate Attention to Details: Overlooking instructions, such as not attaching a photo where required or not following the format for answering questions, may result in your application being rejected.

Documents used along the form

When applying for licensure as an EMS provider in Georgia, several additional forms and documents are often required alongside the C 08 B Georgia form. Each of these documents plays a crucial role in the application process, ensuring that all necessary information is collected for a thorough review.

  • License Verification Form: This form is essential for confirming the good standing of an applicant's current EMT or paramedic license from another state. It must be completed by the certifying agency of that state.
  • Background Disclosure Statement: Applicants must provide a detailed written statement if they have any criminal history or have faced disciplinary actions. This statement helps the licensing board assess the applicant's moral character.
  • Proof of CPR Certification: A copy of current CPR credentials is required. This document verifies that the applicant has the necessary life-saving skills essential for EMS professionals.
  • NREMT Wallet Card: A copy of the National Registry of Emergency Medical Technicians (NREMT) wallet card is needed to confirm the applicant's certification status at the national level.
  • Photo Identification: A government-issued photo ID is necessary to verify the identity of the applicant. This helps ensure that the application is processed accurately.
  • National Criminal History Report: Applicants must submit a criminal history report generated within the last twelve months. This report should include identifying information such as name and birthdate.
  • Advanced Tactical Practitioner (ATP) Documentation: For ATP applicants, proof of passing the written exam and current credentials must be included. This verifies that the applicant meets specialized training requirements.
  • Affidavit of Applicant: This document confirms that the applicant has answered all questions truthfully and consents to an investigation into their professional background. It must be signed and notarized to be valid.

Gathering these documents is a vital step in the licensure process. Each piece of information contributes to a comprehensive understanding of the applicant's qualifications and background, ensuring that only qualified individuals serve as EMS providers in Georgia.

Similar forms

  • Application for Licensure in Other States: Similar to the C 08 B form, this document requires applicants to provide personal information, proof of credentials, and undergo a background check. Both forms ensure that applicants meet the necessary qualifications for licensure in their respective states.
  • National Registry of Emergency Medical Technicians (NREMT) Application: This application also asks for proof of training and certification, as well as a background check. Like the C 08 B form, it emphasizes the importance of maintaining current certifications and credentials.
  • State Certification Renewal Forms: These forms share similarities with the C 08 B in that they require applicants to submit documentation proving continued education and current certifications. Both processes help ensure that professionals remain qualified to serve.
  • Emergency Medical Services (EMS) Background Check Forms: These documents focus on the applicant's criminal history and moral character, similar to the background disclosure section in the C 08 B form. Both seek to protect public safety by vetting applicants thoroughly.
  • Affidavit of Applicant Forms: Just like the C 08 B form, these affidavits require applicants to attest to the truthfulness of their submissions. Both forms emphasize the legal implications of providing false information.
  • Continuing Education Documentation: This document is akin to the requirements in the C 08 B form that mandate proof of ongoing training and certifications. Both highlight the necessity for professionals to stay updated in their field.
  • License Verification Requests: Similar to the verification section in the C 08 B form, these requests seek confirmation of an applicant's standing with previous licensing boards. Both ensure that the applicant's credentials are valid and recognized.

Dos and Don'ts

When filling out the C 08 B Georgia form for out-of-state licensure, it is essential to follow specific guidelines to ensure a smooth application process. Here’s a list of six important dos and don’ts:

  • Do print clearly or type your information. This helps prevent any misunderstandings.
  • Do double-check your personal information for accuracy. Mistakes can delay your application.
  • Do include all required documents, such as your CPR credentials and NREMT wallet card. Incomplete applications may be rejected.
  • Do ensure that your payment is in the correct form, such as a money order or cashier's check. Cash is not accepted.
  • Don’t leave any questions unanswered. Each section must be filled out completely to avoid processing delays.
  • Don’t forget to sign and date your application. An unsigned application may be considered invalid.

By adhering to these guidelines, applicants can enhance their chances of a successful and timely application process. Remember, attention to detail is key when submitting important documents like these.

Misconceptions

Misconceptions about the C 08 B Georgia form can lead to confusion and delays in the application process. Here are five common misunderstandings:

  • Only EMTs can apply using this form. Many believe that the C 08 B form is exclusive to EMTs. In reality, it is applicable to various levels of emergency medical service providers, including paramedics and advanced tactical practitioners.
  • The application fee is refundable. Some applicants assume that the $75 to $150 fee can be refunded if their application is denied. However, this fee is non-refundable, regardless of the outcome of the application.
  • Background checks are optional. There is a misconception that providing a background check is not necessary. In fact, a national criminal history report is a mandatory part of the application process.
  • All documents can be submitted later. Applicants often think they can submit required documents at a later date. However, all necessary documentation must accompany the application when it is submitted to avoid processing delays.
  • Licensure in another state guarantees approval. Some individuals believe that holding a license from another state will automatically ensure their application is approved. While it may help, each application is evaluated on its own merits and must meet Georgia's specific requirements.

Understanding these misconceptions can help streamline the application process and ensure a smoother experience for all applicants.

Key takeaways

When filling out the C 08 B Georgia form, there are several important points to keep in mind:

  • Application Fees: Be aware of the non-refundable application fees, which vary based on your certification level. For initial EMT certification, the fee is $75, while it is $150 for reinstatement after a lapse of two years.
  • Payment Method: Payments must be made using a Money Order, Business Check, or Cashier's Check, and should be payable to the "Georgia Department of Public Health."
  • Documentation Required: You must provide documentation that includes CPR credentials, proof of course completion, and a current NREMT wallet card.
  • Criminal Background Disclosure: Be prepared to answer questions regarding any past arrests or convictions. If applicable, attach a detailed statement and relevant documentation.
  • Processing Time: Applications are typically processed within 5-7 business days from the date they are received, so plan accordingly.
  • Affidavit Requirement: An affidavit must be signed, confirming that all information provided is accurate and that you consent to a background investigation.
  • Notarization: Do not forget to attach a passport photograph and ensure that the notarization section is completed only after the photo is attached.
  • License Verification: If you hold licenses from other states, a separate verification form must be submitted for each license, as your application cannot be processed without them.