ECRN Information Form

ECRN Information Form
General Information
DATE
HOSPITAL
Personal Information
FULL NAME

First NameLast Name
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
COUNTY
DATE OF BIRTH

MonthDayYear
Date
GENDER (M/F)
Contact Information
HOME PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
WORK E-MAIL ADDRESS
example@example.com
HOME E-MAIL ADDRESS
example@example.com
ECRN Details
ECRN TRAINING SITE
DATE COMPLETED

MonthDayYear
Date
ECRN STATE LICENSE NUMBER
LICENSE EXPIRATION DATE

MonthDayYear
Date
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.

State of Illinols
Illinois Department of Public Health
Emergency Medical Services (EMS) SystemsRenewal Notice/Child Support/Personal History Statement
ONLINE RENEWAL AND PAYMENT CAN BE MADE AT www.dph.illinois.gov.
The following statements MUST be completed.
If you have been convicted of a felony, attach a statement, in your own words, of the circumstances surrounding the incident.
An additional fee and authorization for release of information must be submitted to IDPH to obtain a criminal history report
from the Illinois State Police or other law enforcement agency. The release form and fee schedule can be found at
www.dph.illinois.gov.
Birthdate

MonthDayYear
SS#
DL#
E-Mail
example@example.com
Phone Number
Format: (000) 000-0000.
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in
connection herewith, and to the best of my knowledge, they are true, correct and complete. Failure to so certify shall resuit in
the denial of the request for license renewal.
Signature
Date

MonthDayYear
Date
This request for Information is only the first part of the renewal process. Renew online or return this completed form,
with the appropriate fee, to the address provided below. Money order or cashier's check accepted. Do Not Send Cash.
Proof of your continuing education hours MUST be submitted to your EMS System Coordinator or Trauma Nurse Specialist
Course Coordinator (whichever applicable) for review and approval.
If you are an independent, go to dph.illinois.gov and complete the Independent Renewal and follow the instructions for mailing.

License renewal will not be processed until all information and payment are completed and received.
Name/Address Update — Complete this section only if your name or address has changed since your last licensure renewal.

Ex. Marriage/Divorce Name Change
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Return to:

Illinois Department of Public Health
Division of EMS and Highway Safety
Attention: Licensure Section
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
ICCI 17-149 11/16
Printed by Authority of the State of Elinois
Should be Empty:

ECRN Information Form

General Information

Personal Information

Contact Information

ECRN Details

Emergency Medical Services (EMS) SystemsRenewal Notice/Child Support/Personal History Statement

Name/Address Update — Complete this section only if your name or address has changed since your last licensure renewal.