I hereby certify under penalty of perjury that I am not precluded from authorization for those reasons defined in section 1798.200 of the Health and Safety Code, which are as follows:
1. Fraud in the procurement of any certification under this division.
2. Gross negligence.
3. Repeated negligent acts.
5. The commission of any fraudulent, dishonest or corrupt act that is substantially related to the qualifications, functions and duties of prehospital personnel.
6. Conviction of any crime which is substantially related to the qualifications, function and duties of prehospital personnel. The record of conviction or a certified copy of the record shall be conclusive evidence of the conviction.
7. Violating or attempting to violate directly or indirectly or assisting in abetting the violation of, or conspiring to violate any provision of this division or the regulations promulgated by the authority pertaining to the prehospital personnel.
8. Violating or attempting to violate any federal or state statute or regulation which regulates narcotics, dangerous drugs or controlled substances.
9. Addiction to, the excessive use of, or the misuse of alcoholic beverages, narcotics, dangerous drugs or controlled substances.
10. Functioning outside the supervision of medical control in the field care system operating at the local level, except as authorized by any other license or certification.
11. Demonstration of irrational behavior or occurence of a physical disability to the extent that a resonable and prudent person would have reasonable cause to believe that the ability to perform the duties normally expected may be impaired.
I have read and understand Section 1798.200 of the Health and Safety code (above). I am not precluded from being authorized for any reason defined in Section 1798.200 or I have enclosed a complete explanation of any item that applies to me.