Highland Park EMS System Paramedic Information Form

HIGHLAND PARK HOSPITAL EMS SYSTEM
It is the individual’s responsibility to notify the EMS office of any change on this form within 10 days.
Todays Date*

MonthDayYear
Date
Name*
Date of Birth*
Home Address*
City*
State*
Zip Code*
County*
Work E-mail Address*
example@example.com
Personal E-mail Address*
example@example.com
Cell Phone*

Area CodePhone Number
Home Phone*

Area CodePhone Number
EMT-B: Training Site
Date Completed

MonthDayYear
Date
License Renewal Date

MonthDayYear
Date
Paramedic: Training Site
Date Completed

MonthDayYear
Date
State License
Expiration Date

MonthDayYear
Date
Primary EMS System*
Primary Ambulance Affiliation*
Secondary EMS System(s)
Secondary Ambulance Affiliation(s)
System Entry Date*

MonthDayYear
Date
System #*
CPR Card*

Browse Files

Cancelof
Drivers License*

Browse Files

Cancelof
EMT-P Illinois State License*

Browse Files

Cancelof
Letter of Good Standing

For Paramedics from Another EMS System:

Please contact your current EMS system to obtain a letter of good standing. Indicate the EMS system and the person contacted for this letter. If the letter request is sent via email, please cc Hortensia "Tensy" Rodriguez at HRodriguez@northshore.org for assistance and facilitation.

For Independent Paramedics or Recent Graduates:

A letter of good standing is required in the form of a formal letter from the program director of your paramedic school.
EMS System Contacted for Letter of Good Standing
Name of Person Contacted for Letter of Good Standing

First NameLast Name
Note: Please be advised that a Social Security number and Driver’s License or State ID number are required during the initial licensure and relicensure process.

Contact the EMS office with questions. EMS Department:(847) 480 3758
Type of License Requiring Updated Information
Should be Empty:

HIGHLAND PARK HOSPITAL EMS SYSTEM