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Notes / Application Instructions:

Please complete all question fields of the application.

Completed applications must include the following documentation:

A. NEW APPLICANT - Completed a Canadian Medical Association (conjoint committee on accreditation of allied health services) approved training program within the two years preceding this application.

Required documentation:
• i) copy of EMT program certificate;
• ii) successful completion of an approved entry to practice examination (ex. COPR);

B. NEW APPLICANT - As an EMT, participated in at least 20 emergency call-outs during the 2 years preceding this application.

Required documentation:
• i) Emergency Call-Out Form

C. RE-LICENSING :
• i) Actively practiced as an EMT by participating in at least 10 Emergency Call-Outs within the 2 years preceding this application.
• ii) Successfully accumulated 20 continuing education units (CEUs) within the 2 years preceding this application.
  
  An EMT who has been licensed for less than 2 years will have requirements pro-rated based on the length of time they have held their current license.


Required documentation:
• i) Emergency Call-Out Form
• ii) Continuing Education Units (CEUs) Form

D) LAPSED LICENSE – (1 day to less than 1 year expired) I am applying for a conditional license and I acknowledge that I must provide required proof of completing 10 emergency call-outs, and have successfully accumulated 20 CEUs within 60 days of being granted a conditional license.

Required documentation:
• i) Emergency Call-Out Form
• ii) Continuing Education Units (CEUs) Form (

E) LAPSED LICENSE – (1 year to 3 years expired) I am applying for a conditional license and I acknowledge that I must complete 420 hours of preceptored EMS work (with an approved preceptor) at my previous level; I must obtain a minimum of 75 patient care trips, of which at least 15 must documented emergency call-outs; and I must submit successful accumulation of 20 CEU within 6 months of being granted a conditional license.

Required documentation:
• i) Emergency Call-Out Form
• ii) Continuing Education Units (CEUs) Form

1) Application for EMT License Level:
EMT - I: *
EMT - II: (application type C only)
EMT - III:
2. Type of Application:
(License Type A): *
(License Type B):
(License Type C):
(License Type D):
(License Type E):
Option to submit all required documentation with application:
3. Personal Information:
Last Name: *
First Name: *
Middle Name: *
Any Former Name: *
Mailing Address: *
Street Address: *
City: *
Province: *
Postal Code: *
Email Address: *
Phone: *
4. Criminal Record Check:
Have you ever been convicted of a criminal offense under any federal or provincial statute(s) or do you have any outstanding charges?: *	Yes No
Please submit a valid criminal record check. :
5. Paramedic Education:
Paramedic School: *
Title of Program / Level: *
Graduation Date: *
New applications must submit a copy of their EMT program certificate.:
If you have gained additional competencies above your licensure level, please indicate below the additional competencies for which you determine to be competent.: *
Please submit a copy of each competency certificate.:
6. Paramedic Experience:
Have you ever been previously licensed in PEI as an EMT?: *	Yes No
If yes, at what level?:
License Number?: *
Number of years experience in ambulance service work?: *
Where did you first obtain registration?: *
Date: *
Are you currently employed as an EMT on PEI?: *	Yes No
Are you currently registered in another province or country?: *	Yes No
Please submit a verification of registration from each of the other licensing bodies.:
7. Registration Status:
Is your professional conduct or practice currently under investigation?: *	Yes No
Have you ever been denied a license?: *	Yes No
Have you ever been disciplined by a professional regulatory body?: *	Yes No
Have you ever been suspended, dismissed or de-registered as an EMT or equivalent?: *	Yes No
Has your license in another province ever been revoked, suspended or had conditions attached?: *	Yes No
ADVISORY All applicable certificates, documents, and fee payment must be submitted prior to the assessment of this application. Documents can be submitted to the EHS Coordinator; 16 Garfield Street, PO Box 2000, Charlottetown, PE C1A 7N8 Incomplete applications for license renewal are subject to late renewal fees.
FEES Registration (or renewal of Registration) fee is $100.00
I hereby declare the information contained in this application and the attachments to be true and valid. I understand that (1) falsification of this application, or (2) the submission of any falsified documents to the PEI Emergency Medical Services (EMS) Board, or (3) the submission of any falsified EMS Board documents to other agencies, may be sufficient cause for the EMS Board to withhold a license, to revoke a license, or to take other appropriate action.
Date: *
Applicant Signature: *
FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT EMS Board Compliance Statement Personal information on this form is collected by the EMS Board under the authority of the Prince Edward Island’s Public Health Act (sections 25 and 38) and Emergency Medical Services Regulations (sections 16, 17, and 18). This information will be used to determine eligibility for an EMT license and to maintain a register of licensed EMTs in the province. The collection, use, or disclosure of this information must be in accordance with the Freedom of Information and Protection of Privacy Act, R.S.P.E.I. 1998, c.F-15.01. If you have any questions about this collection of personal information, contact the Provincial Emergency Health Services Coordinator, Health PEI, PO Box 2000, Charlottetown, PE, C1A 7N8. Phone: (902) 368-6237

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