Free 52465.FH11 - Indiana

PARAMEDIC APPLICATION FOR RECIPROCITY
State Form 52465 (R / 10-07) DEPARTMENT OF HOMELAND SECURITY

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INDIANA DEPARTMENT OF HOMELAND SECURITY Certification Supervisor 302 West Washington Street, Room E239 Indianapolis, Indiana 46204 Telephone: (800) 666-7784

INSTRUCTIONS:

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Applicant must be affiliated with a certified paramedic provider organization. Applicant must hold current registration by the National Registry of Emergency Medical Technicians as a Paramedic. Any non-resident of Indiana who possesses a Paramedic certificate or license that is valid in another state upon residing at an Indiana address may apply to the agency for temporary certification as a Paramedic. a. Upon receipt of a valid application and verification of valid status, the agency may issue a temporary certification that will be valid for the duration of the applicants current certificate or license, or for a period not to exceed six (6) months from the date that the request for reciprocity was approved by the director, whichever time period is shorter. b. A person receiving temporary certification may apply for full certification upon proof of registration as a Paramedic by the National Registry of Emergency Medical Technicians. Please complete this form and return it to the above address.

Name of applicant (last, first, middle) Mailing address (number and street, city, state, and ZIP code) Identification number (drivers license number or state identification number) In what state are you currently certified as a Paramedic? National Registry certification number Current state certification number Date of expiration (month, day, year)

Daytime telephone number

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Date of birth (month, day, year) Date of expiration (month, day, year) Have you ever been charged or convicted of a crime other than minor traffic violations?

Yes

No

Signature of applicant

Date (month, day, year)