CALIFORNIA EMERGENCY MEDICAL SERVICES AUTHORITY
PARAMEDIC LICENSURE PROGRAM
10901 Gold Center Drive, Ste. 400, Rancho Cordova, CA 95670-6073
TELEPHONE (916) 323-9875 / FAX (916) 324-2875
STATE OF CALIFORNIA
STATE USE ONLY
P.M.________Rec:_______By:_____
1st $_____ Type: _____ R#: _______
2nd $____ Type: _____ R#: _______
Scanned
QC
INITIAL IN-STATE PARAMEDIC LICENSE APPLICATION
This application is for applicants who have successfully completed an approved paramedic
training program in the state of California.
Please type or print Clearly. The non-refundable fee in the amount of $300 may be paid by
credit card (complete credit card authorization form), check, or money order made payable to EMS PERSONNEL FUND.
PERSONAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE INITIAL:
DATE OF BIRTH (MM/DD/YYYY):
SOCIAL SECURITY NUMBER (SSN) or TAXPAYER ID NUMBER (TIN):
Required, per Health &
Safety Code 797.172(c)
RESIDENTIAL ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE NUMBER:
CELL PHONE NUMBER:
EMAIL ADDRESS: Do not send EMSA correspondence via email
MAILING ADDRESS (EMSA will send official correspondence to this address)
Same as residential. If not, complete the below:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
TRAINING PROGRAM AND EMT CERTIFICATION
PARAMEDIC TRAINING COURSE(attach copy):
EMT CARD NUMBER, if certified in California (attach
copy):
NATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS (NREMT)
PARAMEDIC WRITTEN EXAM DATE:
PARAMEDIC PRACTICAL EXAM DATE:
REGISTRATION CARD NUMBER (attach copy):
LIVE SCAN FINGERPRINT SUBMISSION
LIVE SCAN DATE (attach copy of form):
EMPLOYER INFORMATION (IF KNOWN)
EMPLOYER NAME:
EMPLOYER PHONE NUMBER:
EMPLOYER ADDRESS:
QUESTIONNAIRE
1. Have you ever been convicted of any 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?
YES NO
2.
Are any criminal charges currently pending against you?
YES NO
3. Have you ever had a healthcare certification, accreditation, or license denied, suspended, revoked, fined,
placed on probation, or are you currently under investigation at this time?
YES NO
If you marked YES to any of these questions, attach a detailed statement describing the accusation,
charge(s)/conviction(s), case number, date, location, court, sentence served, parole or probation status, etc. Refer to
instructions for more details.
SIGNATURE
I hereby certify under penalty of perjury that all information on this application is true and correct to the best of my knowledge and belief, and
I understand that any falsification or omission of material facts may cause forfeiture on my part of all rights to paramedic
licensure in the State
of
California. I understand all information on this application is subject to verification, and I hereby give my express permission for the EMS
Authority to contact any person or agency for information related to my role and function as a paramedic in California.
SIGNATURE OF APPLICANT DATE
CONTINUE NEXT PAGE (INSTRUCTIONS) Form # L-01 Revised 05/2021
Page 1 of 2
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Initial In-State Paramedic License Application
INSTRUCTIONS
Complete the Initial In-State Paramedic License Application. Do not leave any
sections blank. Incomplete applications will be returned.
Sign and date the application. Only original signatures are accepted.
Attach a copy of one of the following official identification documents:
- Valid U.S. State Dept. of Motor Vehicles Real ID, Driver’s License, or ID card
- Valid government or country issued photo ID
- Passport: U.S. or unexpired, valid foreign passport with valid U.S. visa and approved U.S.
Department of Homeland Security Lawful Record of Admission
- Birth Certificate: Certified U.S. or U.S. Territory
- Government Issued Military ID with Date of Birth
- U.S. Lawful Permanent Resident card
- U.S. Lawful Resident Alien card
Attach copy of paramedic course completion certificate.
Attach copy of either a current National EMT- P Registry (NREMT) card or proof of
passing the NREMT written and practical exams within the last two (2) years. Exam
results are available on the NREMT website at www.NREMT.org.
Acceptable documents (other than NREMT card) are as follows:
• Copy of congratulations letter.
• Copy of written and practical exam results.
• Copy of NREMT certificate.
• NREMT website printout with your name and the NREMT registry number.
Attach a copy of the completed Live Scan Service, Form #BCII 8016. A list of Live
Scan locations is available on the Department of Justice (DOJ) website at
https://oag.ca.gov/fingerprints/locations.
If you answered YES to any questions in the Questionnaire section, attach a detailed
statement describing the charge(s)/conviction(s) case number, date, location, court,
sentence served, parole or probation if any. You may attach applicable certified court
documents and police reports to help expedite the review of your application.
Include payment in the amount of $300.00 with your application.
This non-refundable application fee may be paid by credit card (include a completed credit
card authorization form), check, or money order made payable to EMS PERSONNEL FUND.
Mail the application, payment, and required documents to the following address:
California Emergency Medical Services Authority
Paramedic Licensure Unit
10901 Gold Center Drive, Suite 400
Rancho Cordova, CA 95670
For additional information:
View our Frequently Asked Questions (FAQ’s) and Informational Videos at
http://www.emsa.ca.gov/Paramedic or
Send inquiries to the Emergency Medical Services Authority at paramedic@emsa.ca.gov or
Contact the Paramedic Licensure Unit by phone at (916) 323-9875.
Page 2 of 2
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
GAVIN NEWSOM, Governor
EMERGENCY MEDICAL SERVICES AUTHORITY
10901 GOLD CENTER DR., SUITE 400
RANCHO CORDOVA, CA 95670
(916) 322-4336 FAX (916) 324-2875
INSTRUCTIONS FOR COMPLETING REQUEST FOR LIVE SCAN SERVICE
APPLICANT SUBMISSION FORM
As authorized by Health & Safety Code Section 1797.172 all new applicants for licensure as a
Paramedic and Paramedics whose licenses have lapsed beyond one year are required to submit
fingerprints for a California Department of Justice (DOJ) criminal history check and a Federal Bureau
of Investigation (FBI) criminal history check.
The Applicant Live Scan process for the submission of fingerprints and the automated criminal
history check and response replaces the blue and white fingerprint card previously used.
You may download a Request for Live Scan Service Applicant Submission form from the EMS
Authority’s website at www.emsa.ca.gov/licensure_forms_and_applications. Please refer to the
attached instructions sheet for completing the Request for Live Scan Services Applicant Submission
Form. Live Scan terminals where you can go to be fingerprinted are located in sheriffs’ offices and
police departments throughout the state as well as public applicant Live Scan sites. A list of Live
Scan terminal locations can be found on the Internet at the DOJ Live Scan web site at
http://ag.ca.gov/fingerprints/publications/contact.php.
Fingerprint fees for processing the criminal history check are established by DOJ and may be
subject to change. The current nonrefundable fee for this process is $49 ($32 for the state and $17
for the federal background checks) and is payable to the Department of Justice or to the Live Scan
Agency doing the fingerprinting. The “rolling fee” for Live Scan fingerprinting, which is separate from
the fee for processing the criminal history check(s), is paid directly to the agency conducting the Live
Scan fingerprinting, and may vary by agency.
The EMS Authority will receive the results of the criminal history check(s) electronically within seven
to ten days of being fingerprinted in most cases. However, if manual processing is required, it may
take longer to receive the results and in some rare cases it may take as long as 30 days or more.
IMPORTANT: Please refer to the attached instruction sheet for completing the Live Scan Applicant
Submission Form. If the form is not completed correctly, the fingerprints may be rejected by DOJ
and you will be required to have your fingerprints taken again (there should be no charges for
reprinting rejected fingerprints providing you take the reject notice with you when you go to be
reprinted).
FBI Inquiries- If after reviewing his/her identification record, the subject thereof believes that it is
incorrect or incomplete in any respect and wishes changes, corrections or updating of the
alleged deficiency, he/she should make application directly to the agency which contributed the
questioned information. The subject of a record may also direct his/her challenge as to the
accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information
Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306.
The FBI will then forward the challenge to the agency which submitted the data requesting that
agency to verify or correct the challenged entry. Upon the receipt of an official communication
directly from the agency which contributed the original information, the FBI CJIS Division will
make any changes necessary in accordance with the information supplied by that agency. [Order
No. 1134-86, 51 FR 16677, May 6, 1986, as amended by Order NO. 2258-99, 64 FR 52226, Sept. 28,
1999] Federal Code of Regulations, Title 28, Section 16.34.
INSTRUCTIONS
All areas indicated on form must be filled in with the information noted below. Please type
or print information clearly. TAKE THE ORIGINAL AND TWO COPIES OF THE FORM TO THE LIVE
SCAN AGENCY WHEN YOU HAVE YOUR FINGERPRINTS DONE.
ORI
The ORI number for the EMS
Authority is A0536.
Job Title or Type of License,
Certification or Permit:
Paramedic
Mail Code
The five digit mail code assigned
by DOJ is 02531.
Name of Applicant
Indicate complete name. Last
Name, First Name and Middle
Initial.
Date of Birth
Indicate month-day-year of birth.
Height
Indicate your height in feet and
inches.
Eye Color
Indicate eye color.
Place of Birth
Indicate the state or country of
birth.
Driver’s License No.
Indicate your California Driver’s
License Number.
Type of Application
License
Agency Address Set Contributing
Agency
Emergency Medical Services Authority
10901 Gold Center Drive, Ste.400
Rancho Cordova, CA. 95670-6073
Contact Telephone Number
(916) 323-9875
Alias
Indicate other names used (i.e.,
nickname, maiden name and/or
alias name{s}).
Sex
Check either Male or Female.
Weight
Indicate your weight in pounds.
Hair Color
Indicate hair color.
SOC
Indicate your Social Security
Number.
Level of Service
Check the FBI and DOJ boxes.
Do not fill in any other areas on the Request for Live Scan Applicant Submission Form.
Verify that the Live Scan Operator has entered the correct information before transmitting.
Verify that the Live Scan Operator has entered the ATI No.
in the bottom portion of the
Request for Live Scan Service Applicant Submission Form.
STATE OF CALIFORNIA
BCIA 8016
(Rev. 03/2019)
DEPARTMENT OF JUSTICE
PAGE 1 of 2
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
A0536
ORI (Code assigned by DOJ)
EMT/PARAMEDIC/MOB INT NURSE
Authorized Applicant Type
Paramedic
Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)
Contributing Agency Information:
Emergency Medical Services Authority
02531
Agency Authorized to Receive Criminal Record Information
Mail Code (five-digit code assigned by DOJ)
10901 Gold Center Drive, Ste. 400
Street Address or P.O. Box Contact Name (mandatory for all school submissions)
Rancho Cordova, CA 95670-6073
City State ZIP Code
Contact Telephone Number
Applicant Information:
Last Name
Other Name
(AKA or Alias)
Last
Sex
Male
Female
Date of Birth
Height
Weight Eye Color
Hair Color
Place of Birth (State or Country)
Social Security Number
Home
Address
Street Address or P.O. Box
First Name Middle Initial
Suffix
First
Suffix
Driver's License Number
Billing
Number
(Agency Billing Number)
Misc.
Number
(Other Identification Number)
City State ZIP Code
DOJ FBI
Level of Service:
Your Number:
OCA Number (Agency Identifying Number)
(If the Level of Service indicates FBI, the fingerprints will be used to check the
criminal history record information of the FBI)
If re-submission, list original ATI number:
Original ATI Number
(Must provide proof of rejection)
Employer (Additional response for agencies specified by statute):
Employer Name
Mail Code (five digit code assigned by DOJ)
Street Address or P.O. Box
City State ZIP Code
Telephone Number (optional)
Live Scan Transaction Completed By:
Name of Operator Date
Transmitting Agency LSID ATI Number Amount Collected/Billed
ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency
✔
✔
STATE OF CALIFORNIA
BCIA 8016
(Rev. 03/201p)
DEPARTMENT OF JUSTICE
PAGE 2 of 2
REQUEST FOR LIVE SCAN SERVICE
Privacy Notice
As Required by Civil Code § 1798.17
Collection and Use of Personal Information. The California Justice Information Services (CJIS)
Division in the Department of Justice (DOJ) collects the information requested on this form as authorized
by Business and Professions Code sections 4600-4621, 7574-7574.16, 26050-26059, 11340-11346, and
22440-22449; Penal Code sections 11100-11112, and 11077.1; Health and Safety Code sections 1522,
1416.20-1416.50, 1569.10-1569.24, 1596.80-1596.879, 1725-1742, and 18050-18055; Family Code
sections 8700-87200, 8800-8823, and 8900-8925; Financial Code sections 1300-1301, 22100-22112,
17200-17215, and 28122-28124; Education Code sections 44330-44355; Welfare and Institutions Code
sections 9710-9719.5, 14043-14045, 4684-4689.8, and 16500-16523.1; and other various state statutes
and regulations. The CJIS Division uses this information to process requests of authorized entities that
want to obtain information as to the existence and content of a record of state or federal convictions to
help determine suitability for employment, or volunteer work with children, elderly, or disabled; or for
adoption or purposes of a license, certification, or permit. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's
general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. All the personal information requested in the form must be provided.
Failure to provide all the necessary information will result in delays and/or the rejection of your request.
Access to Your Information. You may review the records maintained by the CJIS Division in the DOJ
that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to process applications pertaining to Live Scan
service to help determine the suitability of a person applying for a license, employment, or a volunteer
position working with children, the elderly, or the disabled, we may need to share the information you give
us with authorized applicant agencies.
The information you provide may also be disclosed in the following circumstances:
∙ With other persons or agencies where necessary to perform their legal duties, and their use of
your information is compatible and complies with state law, such as for investigations or for
licensing, certification, or regulatory purposes;
∙
To another government agency as required by state or federal law.
Contact Information. For questions about this notice or access to your records, you may contact the
Associate Governmental Program Analyst at the DOJ's Keeper of Records at (916) 210-3310, by email at
[email protected], or by mail at:
Department of Justice
Bureau of Criminal Information & Analysis
Keeper of Records
P.O. Box 903417
Sacramento, CA 94203-4170
STATE USE ONLY
CALIFORNIA EMERGENCY
MEDICAL SERVICES AUTHORITY
PARAMEDIC LICENSURE
PROGRAM
10901 Gold Center Drive, Ste. 400, Rancho Cordova, CA 95670-6073
TELEPHONE (916) 323-9875 / FAX (916) 324-2875
paramedic@emsa.ca.gov
Receipt Number:
CREDIT CARD AUTHORIZATION FORM
Applicant Name: P-Number
(If applicable)
Name:
Card Type:
Visa
Mastercard
Debit
(As name appears on card)
C
re
dit C
ar
d
N
u
m
b
er:
*Only Visa and Mastercard credit cards are accepted
Expi
rat
ion D
ate
(M
M
/YY)
:
CVC
2
Cod
e
(Securit
y
Cod
e): B
illin
g
Zip Cod
e:
Payment Amo
un
t:
Sign
at
u
re
of C
ar
dhold
er:
To receive a receipt of payment, please provide your email address:
Do not add application information to this form.
It will be
shre
dded.
Revised: 10/30/18
Created: 04/14/16
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