SWORBHP Certification for Paramedic

***THIS FORM MUST BE COMPLETED BY THE PARAMEDIC***

Part A: PARAMEDIC INFORMATION
Part B: EDUCATION INFORMATION

Paramedic Education Program

Paramedic Education Program

Paramedic Education Program

Paramedic Education Program

Paramedic Education Program

Part C: CERTIFICATION HISTORY

Please include all certification history that has occurred within the 10 year period immediately preceding the application.

Current/Most Recent Employment

Cross Certification:
SWORBHP will recognize auxiliary directives you obtained at another previous Base Hospital if the requirements for cross certification have been met. To make a request for cross certification, please complete our Cross Certification Form (this link will open in a new window) in addition to completing this form.

Additional Employment

Additional Employment

Additional Employment

Additional Employment

Part D: DEACTIVATION/DECERTIFICATION HISTORY

Please declare all previous deactivations and/or decertifications that have occurred within the 10 year period immediately preceding the application.

Part E: RELEASE OF INFORMATION AUTHORIZATION
PART F: ATTESTATION

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