The C 08 B Georgia form is an application used for obtaining out-of-state licensure for Emergency Medical Services (EMS) professionals in Georgia. This form is essential for individuals seeking to practice as EMTs or paramedics after being certified in another state. Completing this application is a crucial step in ensuring that you meet the necessary requirements to serve the citizens of Georgia effectively.
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The C 08 B Georgia form is a crucial document for individuals seeking out-of-state licensure as Emergency Medical Technicians (EMTs) or paramedics in Georgia. This application serves as a comprehensive guide for applicants, outlining the necessary steps and requirements to obtain certification. It includes sections for personal information, such as legal name, Social Security number, and contact details. Applicants must also provide proof of current CPR credentials, completion of an approved training course, and documentation of their National Registry of Emergency Medical Technicians (NREMT) certification. Additionally, the form requires a background disclosure section, where applicants must disclose any past criminal history or previous disciplinary actions related to their professional licenses. The application process involves a non-refundable fee, which varies depending on the level of certification being sought, and all applications are typically processed within a span of five to seven business days. By filling out this form, applicants not only demonstrate their commitment to serving the citizens of Georgia but also affirm their understanding of the regulations governing emergency medical services in the state.
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?
► Are there any criminal charges pending against you?
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?
► Have you ever voluntarily surrendered a certificate or license for any reason?
► 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 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
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
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
Paramedic Certificate
#
______________
Other (specify) ______________________________________
Certificate
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?
B. Has the above certification(s) or license(s) ever been revoked or suspended?
If yes, please explain ______________________________________________________________________
__________________________________________________________________________________________
C.
Has the above listed individual ever been convicted of a felony?
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?
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:
Notes: ____________________________
___________________________________
Completing the C 08 B Georgia form is an important step in your journey toward obtaining your out-of-state licensure as an EMS provider. It is essential to provide accurate information and ensure that all required documentation is included. Once the form is filled out and submitted, it will be processed by the Georgia Department of Public Health, typically within 5-7 business days.
The C 08 B form is an application for out-of-state licensure for Emergency Medical Technicians (EMTs) and Paramedics wishing to practice in Georgia. It is issued by the Georgia Department of Public Health and is part of the process to ensure that applicants meet the necessary certification and background requirements to serve as EMS providers in the state.
Applicants must pay a non-refundable fee that varies based on the level of certification. The fees are as follows:
Payment must be made via Money Order, Business Check, or Cashier's Check, made payable to the "Georgia Department of Public Health."
Applicants must provide several documents, including:
For Paramedic applicants, documentation of current Advanced Cardiac Life Support (ACLS) credentials is also required.
The processing time for the application is typically between 5 to 7 business days from the date it is received by the Georgia Office of Emergency Medical Services and Trauma.
If you have ever been arrested or convicted of a felony or misdemeanor, you must disclose this information in your application. A detailed written statement is required, along with copies of any related records or court documents. This information will be reviewed as part of the background check process.
Yes, the application must be sworn and subscribed before a notary public. This is to certify that all information provided is true and accurate. However, the notary section should only be completed after attaching a passport-sized photograph of the applicant.
Yes, the C 08 B form is specifically designed for out-of-state applicants. You will need to submit verification of your current certification or license from your home state, along with the required documentation outlined in the application.
If you need help completing the application, you can contact the Georgia Department of Public Health or the Office of Emergency Medical Services and Trauma directly. They can provide guidance on the application process and answer any specific questions you may have.
Failing to print clearly or use ink when filling out the form can lead to misinterpretations.
Not providing a current address may delay the processing of your application.
Forgetting to include the non-refundable fee can result in application rejection.
Omitting required documents, such as the NREMT Wallet Card or CPR credentials, will halt your application.
Neglecting to answer background disclosure questions truthfully can lead to serious consequences.
Not signing or dating the application will make it incomplete.
Failing to attach a passport photograph where required can prevent notarization.
Using an incorrect form of payment, such as personal checks, can result in delays.
Not keeping a copy of your submitted application may lead to difficulties in tracking its status.
Overlooking the need for additional statements when answering "yes" to certain questions can cause processing delays.
When applying for the C 08 B Georgia form, several other documents may also be required to ensure a complete application. Each of these documents plays a crucial role in verifying your qualifications and background as an EMS provider. Below is a list of commonly used forms and documents that accompany the C 08 B form.
Gathering these documents will help streamline your application process. Ensure all forms are completed accurately and submitted along with the C 08 B form to avoid delays. Your commitment to serving as an EMS professional is commendable, and thorough preparation will support your application efforts.
The C 08 B Georgia form is similar to the Application for Licensure as a Nurse (Form 2) used by the Georgia Board of Nursing. Both documents require applicants to provide personal information, including legal name, Social Security number, and contact details. Furthermore, each application necessitates proof of current certifications, such as CPR and other relevant credentials. Both forms also include sections for disclosing any criminal history or previous disciplinary actions, ensuring that applicants meet the moral and ethical standards required for licensure in their respective fields.
Another comparable document is the Application for Licensure as a Physician Assistant (PA) in Georgia. Similar to the C 08 B form, this application requires detailed personal information and documentation of current certifications. Applicants must also disclose any past criminal convictions or disciplinary actions. Both forms emphasize the importance of verifying the applicant's qualifications and moral character, which is crucial for maintaining public trust in healthcare professionals.
The Georgia Real Estate License Application shares similarities with the C 08 B form in its structure and purpose. Both documents require applicants to submit personal information and proof of completion of specific training programs. Additionally, they both include sections for background checks, where applicants must disclose any criminal history. This ensures that all professionals seeking licensure in Georgia are thoroughly vetted for their suitability to practice in their respective fields.
Furthermore, the Georgia Bar Application for Admission to the State Bar is akin to the C 08 B form. Each application mandates that the applicant provide comprehensive personal information and documentation of their qualifications. Both forms also require a thorough background check, including the disclosure of any criminal history or disciplinary actions. This process is essential for ensuring that individuals who are granted licenses in their professions uphold the integrity and standards expected by the state.
Lastly, the Application for Licensure as a Physical Therapist in Georgia parallels the C 08 B form in several ways. Both applications necessitate the submission of personal information, proof of educational qualifications, and current certifications. Additionally, both documents include sections for disclosing any criminal background or past disciplinary issues. This ensures that applicants are thoroughly assessed for their fitness to practice and provide safe care to the public.
When filling out the C 08 B Georgia form, consider these important do's and don'ts:
Understanding the C 08 B Georgia form is essential for those seeking licensure as an EMS professional. However, there are several misconceptions that can lead to confusion. Below are some common misunderstandings about this form, along with clarifications.
The application fee is non-refundable. Once submitted, the fee cannot be returned, regardless of the outcome of the application.
This form is required for all levels of certification, including Basic, Intermediate, and Paramedic. Each applicant must complete the C 08 B form to apply.
All required documents must accompany the application. Missing documentation can delay processing or result in denial.
Background checks are mandatory. Applicants must disclose any criminal history and provide a national criminal history report.
Processing typically takes 5-7 business days. Applicants should plan accordingly and not expect instant approval.
Only specific payment methods are accepted: Money Order, Business Check, or Cashier's Check. Personal checks are not allowed.
A government-issued photo ID is a required document for the application. Ensure you have this before submission.
Applicants must disclose any other licenses or certifications. Failure to do so can lead to complications in the application process.
By addressing these misconceptions, applicants can better prepare for the licensure process and ensure a smoother experience. It is crucial to read all instructions carefully and provide complete and accurate information.
When filling out and using the C 08 B Georgia form for out-of-state licensure, it is essential to be aware of several key points to ensure a smooth application process.
Understanding these key points can help facilitate the application process and ensure compliance with Georgia's requirements for EMS licensure.