Initial Certification EMR Application

Emergency Medical Responder Initial Certification Application
SS#*
Certification #
Transferring ONLY
Current Certification expiration:

MonthDayYear
Currently Expired:

YesNo
Name*

LastFirstMI (N/A if not applicable)Suffix
Home Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
I have taken and successfully passed the Mountain-Valley EMR written exam?*

YesNo
Stop Here: Please call Mountain-Valley @ 209-529-5085 to schedule exam
I would like my card(s):*

Mailed - Card will be mailed to address on applicationPick Up - You will be notified via email when ready
Per Instructions: Please allow 5-7 business days for processing
Phone Number*
Format: (000) 000-0000.
Driver's License #*
Birth Date*

MonthDayYear
Age Range:*
Gender:*
Race/Ethnicity:*
Email*

Confirmation Email
Primary EMS Employer:
Other Employer
YOU MUST ANSWER THESE QUESTIONS OR APPLICATION WILL BE REJECTED
Have you ever been convicted of a felony or misdemeanor offense in California or in any other state or place, including entering a plea of nolo contendere or no contest, and including any conviction which has been expunged (set aside) or records sealed under Penal Code Section 1203.4?*

YesNo
Are there any criminal charges currently pending against you?*

YesNo
If yes, provide a detailed statement below describing the crime(s), date, location, court, sentence served and parole if any and attach supporting documentation.
Statement (required)
Upload Supporting Documents*

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Have you ever had a Certification, Accreditation or professional healing arts license denied, suspended, revoked or placed on probation or are you under investigation at this time?*

YesNo
If yes, attach an explanation that describes the action, any corrective action, and/or remediation as a result of the action.
Upload Supporting Documents*

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The Medical Director shall deny or revoke an EMT or Advanced EMT certificate if any of the following apply to the applicant:

a. has committed any sexually related offense specified under Section 290 of the Penal Code

b. been convicted of murder, attempted murder or murder for hire

c. been convicted of two or more felonies

d. is on parole or probation for any felony

e. been convicted and released from incarceration during the preceding fifteen years of the crime of manslaughter or involuntary manslaughter

f. been convicted and released from incarceration during the preceding ten years for any offense punishable as a felony

g. been convicted of two misdemeanors within the preceding five years for any offense relating to to the use, sale, possession or transportation of narcotics or addictive or dangerous drugs

h. been convicted of two misdemeanors within the preceding five years for any offense relating to force, violence, threat or intimidation

i. been convicted within the preceding five years of any theft related misdemeanor

j. has committed any act within the preceding seven years involving fraud or intentional dishonesty for personal gain
I have read and understand the above statements, please initial:*
Required Documents
Upload Required Documents: *

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See Requirements - Please attach all items separately 1 MB limit per attachment Cancelof
Additional documents may be sent via email to Certifications@mvemsa.com, please use last name in subject line.
Applications missing required documentation/information will be delayed.
Payment Information
Initial Certification $30
Debit or Credit (CHECK ALL THAT APPLY)
prevnext( X )
EMR Initial Application Fee$30.00

Total $0.00
NO PAYMENT REQUIRED

YOUR EMPLOYER WILL BE INVOICED FOR CERTIFICATION FEES
PLEASE NOTE: APPLICATION WILL NOT BE PROCESSED UNTIL PAYMENT IS RECEIVED
Print Name:*
Signature*
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Emergency Medical Responder Initial Certification Application

Required Documents

Payment Information