Get First Name Last Name Mi Address City State Zipcode County (first 4 ... - Health Ny

This guide provides clear, step-by-step instructions on how to complete the First Name Last Name MI Address City State Zipcode County (First 4 ... - Health Ny form for the Continuing Education Recertification Program. Follow the instructions carefully to ensure your application is submitted correctly.

Follow the steps to successfully complete your form

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Fill in your first name in uppercase letters. Ensure that you spell your name correctly to avoid any delays in processing.
3. Enter your last name, also in uppercase letters, directly below your first name.
4. Input your middle initial (MI) if applicable. If you do not have a middle name, leave this section blank.
5. Provide your complete address, including street number and name.
6. Enter your city of residence below the address.
7. Select your state from the dropdown menu, ensuring it reflects your current residence.
8. Fill in your zipcode, maintaining the correct 5-digit format.
9. Input the first four letters of your county's name in uppercase letters.
10. Indicate your gender by selecting ‘M’ for male or ‘F’ for female.
11. Provide your social security number in the designated field.
12. Enter your phone number, including the area code, in the provided section.
13. Fill in your EMT/AEMT number if applicable.
14. Input the expiration date of your certification in the specified format.
15. Provide your date of birth in the designated format.
16. Select your certification level from the options available: EMT-B, AEMT-I, AEMT-CC, or EMT-P.
17. Input your agency code for the participating agency.
18. Indicate your certification instructor code (CIC) or certification lead instructor code (CLI) if applicable.
19. Enter your email address to receive important updates and notifications.
20. Read the personal affirmation carefully and check the box only if there are no relevant criminal convictions.
21. Sign the applicant's signature section.
22. Date the application form.
23. Submit your completed form according to the provided submission instructions. You may choose to save changes, download, print, or share the form.

Complete your documents online to ensure timely processing.