Get Application 2011 0018 Cosponsor Application - Department Of Health

Filling out the Application 2011 0018 Cosponsor Application online can streamline the process of submitting your sponsorship information to the Department of Health. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete your application accurately.

1. Click the ‘Get Form’ button to access the Application 2011 0018 Cosponsor Application and open it in your preferred online editor.
2. Fill out the provider information section at the top of the form. Enter your last name, first name, middle initial (if applicable), DC certification number, and certification level, selecting one of the options provided.
3. Complete the expiration date field, ensuring that the date is accurate and reflects when your certification will expire.
4. Sign and date the certification section, confirming that the information you provided is true and complete. Ensure you agree to surrender your certification card as stipulated.
5. Proceed to the primary sponsoring EMS organization section. Here, the medical director must provide their signature and date to verify your membership and competence within the organization.
6. Next, move to the secondary sponsoring EMS organization section. The medical director here must also sign and date, attesting to your application for membership in their organization while acknowledging your current primary sponsorship.
7. Review all the information entered for accuracy and completeness before finalizing your form. Ensure all required signatures are obtained and dated.
8. Once everything is completed, save your changes, and download or print the form for submission.
9. Submit the completed form to the State EMS Officer at the Department of Health, following the provided address to ensure timely processing.

Complete your Application 2011 0018 Cosponsor Application online today for a smooth submission process.