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Get INITIAL APPLICATION - Ohio Department Of Public Safety - Publicsafety Ohio

(*), must be completed. (Please print legibly and use black or blue ink.) The purpose of this form is to apply for an initial EMS Instructor certificate to teach. For information on certification requirements, please visit our webpage at www.ems.ohio.gov. LEGAL LAST NAME* LEGAL FIRST NAME* LEGAL MI HOME ADDRESS (STREET)* P.O. BOX CITY* STATE* HOME PHONE NUMBER ZIP CODE* WORK PHONE NUMBER E-MAIL ADDRESS* SOCIAL SECURITY NUMBER* SUFFIX COUNTY OF RESIDENCE CELL PHONE NUMBER SECONDARY.

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