Get Extension Request Form - Miemssorg

Filling out the Extension Request Form is an essential step for maintaining your certification or license with the Maryland Institute for Emergency Medical Services Systems. This guide provides you with clear instructions to complete the form effectively and accurately.

Follow the steps to complete your Extension Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by clearly filling in your current provider level by checking the box that corresponds to your certification: Emergency Medical Responder, Emergency Medical Technician, Emergency Medical Dispatcher, Cardiac Rescue Technician, or Paramedic.
3. Provide your Social Security Number in the designated field. Ensure accuracy to avoid processing delays.
4. Next, enter your name in the prescribed format, starting with your last name, followed by your first name and middle name, if applicable. Indicate suffixes like Jr. or Sr., if necessary.
5. Fill in your home address, including street, apartment number (if applicable), city, state, and zip + 4 code.
6. Input your phone numbers, including both home and work numbers, ensuring to provide a valid e-mail address for communication.
7. State the reason for your extension within the allocated space. Be concise but descriptive.
8. Respond to the questions regarding past healthcare certifications and potential criminal convictions by selecting 'No' or 'Yes.' If you answer 'Yes' to either question, prepare to submit supplemental documentation as specified.
9. Sign the application in the designated area and input the current date.
10. Upon completing the form, review all entries for accuracy, then save your changes. You can either download, print, or share the completed form as needed.

Complete your Extension Request Form online today to ensure continuous certification.