Emergency Medical Services

Various forms and applications required for licensing of providers and vehicles are below. If you do not find a form you require, please call 609-633-7777.

• Application for New Providers
  • Form
  • Insurance Requirements for Providers [word 36k] [pdf 15k]

• Basic Provider Forms

• Background Check Form
  • Fingerprinting/Background Check" (For all Clinicians, EMTs, Paramedics, Agency Owners, Board Members, etc.)

• Pediatric Assessment Chart [pdf 1m]
  
  
• PEDIATRIC - Sudden Unexplained Infant Death Form A
  
  
• PA/NJ EMT Continuing Education Form (EMS 28)
  
  
• Sample Inspection Forms
  
  
• Quarterly Report Forms
  
  
• Training Fund Forms and Information
  Copies of the Eligibility Form and Scannable Sign-In Sheet must be attached to the Reimbursement Form when submitting for payment.
  • Basic Course Reimbursement Information and Forms
    • Forms
    • Reimbursement Procedure
  • Continuing Education Reimbursement Information and Forms
    • Forms
  • Other Related Forms
    • Annual Usage Form
    • W-9 Vendor Questionnaire Form and Instructions
• Request Materials (On-Line Forms)
  • Ambulance Pediatric Posters Request Form