Paramedic Licensure Renewal Forms
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.
Paramedic Information Form
Personal Information
DATE
*
-
Month
-
Day
Year
Date
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
FULL NAME
*
First Name
Last Name
HOME ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
COUNTY
Contact Information
WORK E-MAIL ADDRESS
*
example@example.com
HOME E-MAIL ADDRESS
example@example.com
CELL PHONE
*
Format: (000) 000-0000.
HOME PHONE
Format: (000) 000-0000.
EMT Certification
TRAINING SITE
DATE COMPLETED
LICENSE RENEWAL DATE
Paramedic Certification
TRAINING SITE
DATE COMPLETED
STATE LICENSE #
EXPIRATION DATE
Back
Next
EMS System Affiliation
PRIMARY EMS SYSTEM
*
PRIMARY AMBULANCE AFFILIATION
*
SECONDARY EMS SYSTEM(S)
SECONDARY AMBULANCE AFFILIATION(S)
SYSTEM ENTRY DATE
SYSTEM #
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.
Revised 04/05/2024
Back
Next
State of Illinols
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems Renewal Notice/Child Support/Personal History Statement
ONLINE RENEWAL AND PAYMENT CAN BE MADE AT www.dph.illinois.gov.
The following statements MUST be completed.
*
I am up-to-date with child support payments.
I am more than 30 days delinquent in complying with a court-ordered child support order.
i do not have to pay child support.
I have NOT been convicted of a felony.
HAVE been convicted of a felony.
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
*
-
Month
-
Day
Year
Date Picker Icon
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
*
-
Month
-
Day
Year
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, Address Change
Return to:
Name
New Name if changing
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
Full Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City, State, ZIP
City, State, ZIP
Street Address Line 2
City
State / Province
Postal / Zip Code
Illinois Department of Public Health
Division of EMS and Highway Safety
Attention: Licensure Section
422 South Fifth Street, Third Floor
Springfield, lilinois 62701
ICCI 17-149 11/16
Printed by Authority of the State of Elinois
Drivers License
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Basic Life Support Card (CPR Card)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Advance Cardiac Life Support - Optional
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Pediatric Life Support - Optional
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional Certifications ( PHTLS, LI, CE etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preview PDF
Submit
Should be Empty: