EMS License Renewal Application EMS License Renewal ApplicationIf you have already submitted your on-line license application and now need to submit additional documentation – Please do not submit another on-line application. Please email the required document(s) directly to EMSlicensing@dos.nh.gov and reference “Missing Parts” in the subject line of the email – Thank You!.Instructions To be able to relicense online you must supply the LIN number that you received in a mailing from the Division and supply a scanned copy of your National Registry Card.Note: You must complete the 2013 Protocol Exam prior to submitting your application for licensure. * = Required FieldRenewal / Change of Level *RenewalChange of LevelLIN *Enter your current National Registry Number *Enter your current NH EMS License number *Full Legal name (Please include middle initial) *Last 4 digits of your SSN *Date of Birth *Best contact phone number *Address *City *State *Zip Code *Email Address *Primary Unit Affliiation information To be a licensed EMS provider in the State of New Hampshire you must be affliated with one licensed EMS unit. If you wish to add an affliation please have the service you wish to add contact the Division. If you wish to remove a service from you license please fill out the change of affliation form and submit it to the Division.Primary Unit Affiliation *EMS Provider License Type *ApprenticeFirst Responder / EMREMT-Basic / EMTEMT-Intermediate/ AEMTEMT-Paramedic / ParamedicNational Registry Verification To be relicensed you must provide documentation that you have reregistered with the National Registry. In the field below please upload a scanned copy of your current registry card or a scanned copy of the national registry website stating you have reregistered.National Registry Verification upload *Please attach any additional documentation that you would like to submit. If your name has changed please provide the appropriate documentation. Additional Documentation Protocol Exam Completion *I have completed the 2013 Protocol ExamProtocol Test Completion Date *Attestation By entering the LIN number that was provided and attesting below I swear or affirm that the information provided is accurate to the best of my knowledge and belief. I have never been convicted of or found guilty of an offense pursuant to RSA 153‐A:13, I (h). I believe that I am in full compliance with RSA 153‐A and the rules adopted thereunder. I understand that providing false information shall be grounds for denial, suspension or revocation of license.Signature *Date signed *FOR INFORMATION PURPOSES ONLY: Applicant Status with Primary Unit: (check one) PaidVolunteerVerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank:
