In our mission to provide continuous delivery of efficient, timely, responsive, and quality customer service, the Bureau of Emergency Medical Services & Trauma System is making several of our applications and forms available for downloading.  The links below are in PDF and Word format.  In order to download the PDF version, Acrobat Reader™ is required.

• EMT Certification Form

• EMT Certification Notification Requirements (Name Change/Address Change) Form

• ALS-BLS Training Program Forms

• Base Hospital Form

• Ambulance Registration Form

• Ground Ambulance Certificate of Necessity (CON) Forms

• Ambulance Revenue and Cost Report (ARCR) Forms

• Complaint Form

• Miscellaneous Forms

EMT CERTIFICATION FORM

• Application for EMT Recertification [DOC 173K]

• Application for Initial EMT Certification [DOC 169K]

• Application for Temporary EMT Certification [DOC 167K]

• Application to Downgrade EMT Certification [DOC 97K]

• Criminal History Addendum [DOC 100K]

• Continuing Education Attestation Form [DOC 73K]

• Regulatory History Addendum [DOC 93K]

• All-in-One Name Change or Address Change and Duplicate/ Replacement Card Form[PDF 56K]  [DOC 910K]

• Training Program Initial Application  [PDF 53K]  [DOC 943K]
• Training Program Application for Amendment  [PDF 42K]  [DOC 72K]
• Training Program Amended Application  [PDF 57K]  [DOC 76K]

  • Course Notification  [PDF 46K]  [DOC 124K] (Updated 11-16-2007)

  • Course Roster  [PDF 37K]  [DOC 191K] (Updated 12-14-2006)

  • Refresher Challenge Examination Roster  [PDF 63K]  [DOC 84K] (Updated 12-14-2006)

    • DOC forms are for electronic submission (Preferred method of submission). Save the DOC file to your computer, fill out the form, and email as an attachment to ems-train@azdhs.gov.

    • Use training program name as subject line. Failure to list training program name in subject line will result in the notification being returned.

    • If email is unavailable, PDF forms can be faxed or mailed to the Bureau.

BASE HOSPITAL FORM

• ALS Base Hospital Application for Certification/Recertification
  [PDF 62K]  [DOC 979K]

AMBULANCE REGISTRATION FORM

• Application for Registration of Ambulance  [PDF 52K]  [DOC 32K]

AIR AMBULANCE LICENSE FORMS

• Air Ambulance License Application [PDF 72K]
• Air Ambulance Registration [PDF 64K]

GROUND AMBULANCE CERTIFICATE OF NECESSITY (CON) FORMS

• Application for Ground Ambulance Service Certificate of Necessity (CON) 
  [PDF 203K]  [DOC 49K]

• General Instructions and Initial Filing Requirements for CON [PDF 72K]  [DOC 29K]

• Application for Ground Ambulance Service CON Renewal [PDF 191K]  [DOC 45K]

• Governmental Entity Ambulance Services Reporting Requirements in Applying Supportive Funding (Tax Levy Funds)  [PDF 96K]  [DOC 84K]

AMBULANCE REVENUE AND COST REPORT (ARCR) FORMS

COMPLAINT FORM

• Complaint Form  [PDF 51K]  [DOC 69K]

MISCELLANEOUS FORMS

• Prehospital Medical Care Directive (Do Not Resuscitate) Form     

• Public Records Request Form  [PDF 198K]  [DOC 106K]