Homepage Fill a Valid C 08 B Georgia Template

Common mistakes

  1. Not using ink or typing: The application must be filled out in ink or typed. Using pencil or other forms of writing can lead to rejection.

  2. Incorrect payment method: Ensure that the payment is made via Money Order, Business Check, or Cashier's Check. Personal checks are not accepted.

  3. Missing required documents: Failing to attach necessary documents, such as CPR credentials or a current NREMT wallet card, can delay processing.

  4. Inaccurate personal information: Double-check that your legal name, Social Security Number, and other personal details are correct. Mistakes can cause significant issues.

  5. Ignoring background disclosure questions: It’s crucial to answer all questions about criminal history honestly. Omitting information can lead to denial of your application.

  6. Not signing the application: Remember to sign and date your application. An unsigned application will not be processed.

  7. Failing to keep a copy: Always make a copy of your completed application and all attached documents for your records. This can be helpful if any issues arise.

  8. Not following up: After submitting your application, be proactive. If you don’t receive confirmation within 5-7 business days, consider following up with the office.

Essential Points on This Form

What is the C 08 B Georgia form?

The C 08 B Georgia form is an application used for out-of-state licensure for Emergency Medical Technicians (EMTs) and paramedics. It is specifically managed by the Georgia Department of Public Health's Office of Emergency Medical Services and Trauma. This form is necessary for individuals who are currently licensed in another state and wish to obtain licensure to practice in Georgia.

What fees are associated with the application?

There are specific fees that must accompany the application. For initial EMT certification, the fee is $75. If you are applying for an Intermediate certification, the fee is $85. For paramedics, the fee remains at $75. If your certification has lapsed for two years or more, the reinstatement fee is $150. It is important to note that these fees are non-refundable and must be paid using a Money Order, Business Check, or Cashier's Check, made payable to the "Georgia Department of Public Health."

What personal information is required on the form?

The application requires several pieces of personal information. Applicants must provide their legal name, Social Security Number (SSN), date of birth, address, phone number, and email address. This information is crucial for processing the application and verifying the applicant's identity.

What documentation must be submitted with the application?

Applicants need to provide various documents to support their application. This includes proof of current CPR credentials, completion of a state-approved course, a copy of the current National Registry of Emergency Medical Technicians (NREMT) wallet card, and a government-issued photo ID. Additionally, EMT-Paramedic applicants must include documentation attesting to current Advanced Cardiac Life Support (ACLS) credentials. A National Criminal History Report is also required, which should be generated no earlier than twelve months prior to submission.

How long does it take to process the application?

Once the application is submitted, it is typically processed within 5 to 7 business days. This timeframe may vary depending on the completeness of the application and the volume of applications being processed at the time.

What should I do if I have a criminal history?

If you have ever been arrested or convicted of a felony or misdemeanor, you must disclose this information on the application. Additionally, you will need to attach a detailed written statement that includes specifics about the crime, such as the date, location, court, sentence served, and any parole conditions. It is essential to be honest and thorough in this section, as failure to disclose this information could affect your application.

What if I have held other licenses or certifications?

If you hold any other licenses or certifications, you must indicate this on the application. You will need to provide the type of certificate or license, the state of issuance, and the certificate or license number along with the date it was issued. This information helps verify your qualifications and experience.

What happens if my application is denied?

If your application is denied, you will receive a notification explaining the reasons for the denial. Depending on the circumstances, you may have the option to appeal the decision or address any issues that led to the denial. It is advisable to carefully review the requirements and ensure all information provided is accurate and complete to avoid any potential denials.

Is notarization required for the application?

Yes, the application must be notarized. However, the notary should only complete the section once a passport photograph is attached to the application. This is to ensure that the identity of the applicant is verified as part of the licensure process.

C 08 B Georgia Sample

GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

EMS OUT-OF-STATE LICENSURE APPLICATION GEORGIA STATE OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA Form C-08-B

APPLICATION – PRINT IN INK OR TYPE

 

Initial EMT Certification Fee - $75*:

 

BASIC

Mail application

State Office of EMS and Trauma

 

Reinstatement Certification Fee

 

INTERMEDIATE 85

and required

ATTN: Personnel Licensure

 

 

 

 

documents to:

2600 Skyland Drive - Lower Level

 

Lapse 2yr of Certification - $150*

 

PARAMEDIC

 

 

 

 

 

Atlanta, GA 30319

 

 

 

 

 

* The non-refundable fee must accompany this application. Payment must be in the form of Money Order, Business Check

or Cashier's Check Only. MAKE ALL FEES PAYABLE TO "GEORGIA DEPARTMENT OF PUBLIC HEALTH"

PERSONAL INFORMATION

Legal Name

 

 

 

 

 

SSN _______ - _____ - __________

 

Last

First

M.I.

 

 

 

Address

 

 

 

 

 

Birth Date

______ - _______ - _________

City

 

 

County _______________

State

 

Zipcode ___________

Phone (______) _______ - __________ E-Mail ____________________________________________________

CERTIFICATION REQUIREMENTS - Applicant shall provide all listed information and/or documents

 

 

Documentation attesting to current CPR credentials

 

 

Proof of completion of a state approved course

 

 

Copy of current NREMT Wallet Card

 

 

Copy of your Federal or State Government

 

 

 

 

 

 

NREMT Registry #

_________________________

 

 

Issued Photo Identification

 

 

 

Current NATIONAL CRIMINAL HISTORY REPORT generated

 

EMT-Paramedic Applicants: Documentation

 

 

 

 

 

no earlier than twelve (12) months prior to submitting an

 

 

attesting to current ACLS credentials.

 

 

 

 

 

 

 

 

application for licensure that includes your name, birthdate and

 

For ATP Applicants ONLY:

 

 

 

at least part of your SSN. Internet searches meeting the above

 

Passed Advanced Tactical Practitioner written

 

 

 

 

 

 

 

 

criteria are accepted.

 

 

 

exam and hold current credentials.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERIFICATIONS

 

 

 

 

 

 

► Do you hold any other license(s) or certificate(s)?

 

 

__ Yes

__ No

 

Kind of Certificate/License and State of Issuance

Certificate/License Number

Date Issued

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

BACKGROUND DISCLOSURE

► Have you ever been arrested and/or convicted of any National, Federal, State or Local felony and/or

misdemeanor offense in Georgia or in any other state or place?

__ Yes

__ No

► Are there any criminal charges pending against you?

__ Yes

__ No

If you answered yes to either of the above questions, attach a detailed written statement, signed and dated, describing the crime(s), date, location, court, sentence served, and parole, if any. Attach copies of all related records, court documents and police reports.

► Have you ever been denied the privilege of taking an examination given by any state licensing board

or been denied a certificate or license?__ Yes __ No ► Have you ever resigned from any employment after a complaint or peer review action has been initiated

against you?

__ Yes

__ No

► Have you ever voluntarily surrendered a certificate or license for any reason?

__ Yes

__ No

► Have you ever had a certification, accreditation or professional healing arts license suspended, revoked

or placed on probation; and/or are you currently under investigation?__ Yes __ No

If you answered yes, attach a detailed written statement, signed and dated, describing the event, investigation, action, any corrective action, and/or remediation as a result of the action.

All applications are processed within 5-7 business days from the date received. Congratulations! Your willingness to serve Georgia’s citizens as an EMS professional is appreciated!

GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

GEORGIA OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA

AFFIDAVIT OF APPLICANT

I acknowledge and state that I have read and answered all questions in compliance with this application. I acknowledge that it is my responsibility to read and become familiar with the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services 111-9-2.

I further state that by filing this application for a license in the State of Georgia, I hereby authorize and consent to have an investigation made as to my moral character, professional reputation and fitness for practice as an EMS provider. I agree to give any further information which may be required in reference to my past record. I understand that I will not receive a copy of the report or know its contents and I further understand that the content of the investigative report will be privileged, unless determined otherwise by the Board or Court Order.

I hereby release, discharge, and exonerate the Georgia Department of Public Health, its agents, representatives, and any person so furnishing information, from any and all liability of every nature and kind arise out of the furnishing or inspection of such documents, records or other information or the investigation made by the Georgia Department of Public Health. I authorize the Georgia Department of Public Health to release information, material, documents, orders of the like relating to me or to this application to any other agency of the State of Georgia, the licensing agency of any other State or Territory of the United States or Province of Canada, a law enforcement agency, a hospital, or other agencies determined by the Board.

This is to certify that the foregoing information is true and correct to the best of my knowledge. I understand that any person who shall give false or forged evidence of any kind to the Board may be prosecuted to the fullest extent allowed by law.

Signature of Applicant

 

Date

 

 

 

 

 

Name Of Applicant

 

City

State

Being duly sworn, says that he/she is the person who executed this application for licensure as an EMS provider in the State of Georgia; and that all the statements herein contained are true in every respect and that the attached photo is a true photo of applicant.

Sworn to and subscribed before me this ______ day of ___________, 20_____.

____________________________________________________

Notary Public

My Commission Expires _______________________________

(SEAL)

Attach Photo Here

Notary: DO NOT notarize this section unless a passport photograph is attached.

FORM C-08-B: OUT-OF-STATE APPLICATION FOR LICENSE

Verifying Person’s Name: _____________________________________
Agency Name: ______________________________________________
Phone Number: ____________________________ Ext: ___________
DO NOT WRITE BELOW THIS LINE
(For OEMS Use Only)

GEORGIA DEPARTMENT OF PUBLIC H EALTH

A Division of Em er gen cy Pr epar edn ess & Respon se

GEORGIA OFFICE OF EMERGENCY MEDICAL SERVICES AND TRAUMA

LICENSE VERIFICATION FORM

This form is used to verify the good standing of EMT or paramedic license or certification applicants who are licensed or certified by another state. Please note that you must submit a separate form for each license and/or certification you hold. Your application cannot be processed without this form.

PART I: Completed by Applicant

Legal Name: _______________________________________________ SSN: ______ - ______ - __________

Current Address: ______________________________________________________________________________

______________________________________________________________________________

I am requesting Georgia license based on the following current license(s) or certification(s):

___ in the state of __________________ AND by the National Registry of EMTs

Current certification(s) or license(s) in another state or issued by the National Registry of EMTs:

EMT - Basic Certificate

# ______________

Expiration Date

____________________

EMT - Intermediate Certificate

# ______________

Expiration Date

____________________

Paramedic Certificate

#

______________

Expiration Date

____________________

Other (specify) ______________________________________

 

 

Certificate

#

______________

Expiration Date

____________________

PART II: Completed by the State Certifying Agency

Please assist by verifying that this individual is currently certified and in good standing according to your certification policies.

A. Is the above-referenced cited certificates(s) or license(s) deemed current and valid according to your

policy?

__ Yes

__ No

B. Has the above certification(s) or license(s) ever been revoked or suspended?

__ Yes

__ No

If yes, please explain ______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

C.

Has the above listed individual ever been convicted of a felony?

__ Yes

__ No

 

If yes, what was the offense? _______________________________________________________________

 

Date of conviction ______________________ Place of conviction ________________________________

D.

Do you know of any reason licensure in Georgia should be denied?

__ Yes

__ No

 

If yes, please explain ______________________________________________________________________

__________________________________________________________________________________________

Title: _________________________

State: _________________________

Date: _________________________

Application Documents

Application Complete

Government Photo ID

Course Completion

NREMT Card

CPR Credentials

Nat'l Criminal Background

Other Certifications

(ATP, ACLS, ETC)

Application Fee

Type: __ M/O __ C/C __ B/C

CH # ________________________

Date: ____/_____/20______

Amount Recv'd: $ _____________

Recv'd by: __________________

 

Certification Status

Status: __ Approved __ Denied

Date:

____/_____/20______

License #

___________________

Exp Date:

____/_____/20______

Notes: ____________________________

___________________________________

___________________________________

Key takeaways

When filling out the C 08 B Georgia form, there are several important points to keep in mind to ensure a smooth application process.

  • Complete the Application Accurately: Make sure to print in ink or type your responses. Double-check all entries for accuracy.
  • Pay the Required Fees: The application fee varies based on your certification level. Ensure that you submit the correct fee in the form of a Money Order, Business Check, or Cashier's Check.
  • Gather Necessary Documents: Include all required documentation, such as CPR credentials, NREMT wallet card, and photo identification. Missing documents can delay your application.
  • Address Background Questions Seriously: If you have any past legal issues, be prepared to provide detailed explanations and supporting documents. Honesty is crucial.
  • Sign the Affidavit: By signing the affidavit, you confirm that all information provided is true and that you consent to a background investigation.
  • Keep Copies: Retain copies of your completed application and all submitted documents for your records. This can be helpful for future reference.
  • Understand Processing Times: Applications are typically processed within 5-7 business days. Plan accordingly if you have time-sensitive needs.
  • Stay Informed: Familiarize yourself with the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services. This knowledge can be beneficial for your practice.
  • Follow Up: If you do not receive a response within the expected timeframe, consider following up with the State Office of EMS and Trauma to check on your application status.

Document Characteristics

Fact Name Description
Form Purpose The C 08 B Georgia form is an application for out-of-state licensure for Emergency Medical Services (EMS) professionals.
Application Fees Initial certification fees vary by level: $75 for Basic, $85 for Intermediate, and $150 for Paramedic if the certification has lapsed for more than two years.
Payment Methods Fees must be paid via Money Order, Business Check, or Cashier's Check, made payable to the Georgia Department of Public Health.
Required Documents Applicants must submit proof of CPR credentials, course completion, NREMT wallet card, and a national criminal history report.
Background Disclosure Applicants must disclose any arrests, convictions, or pending charges, along with detailed statements and supporting documents if applicable.
Processing Time Applications are typically processed within 5-7 business days from the date they are received.
Governing Laws This application is governed by the Georgia Department of Public Health Rules and Regulations for Emergency Medical Services (111-9-2).