License Renewals, Upgrades, & Change of Unit

If you have already submitted your on-line license application and now need to submit additional documentation – Please do not submit another on-line application. Please email the required document(s) directly to EMSlicensing@dos.nh.gov and reference “Missing Parts” in the subject line of the email – Thank You!. Instructions To be able to re-license online you must supply the LIN number that you received in a mailing from the Division and supply a scanned copy of your National Registry Card. Note: You must complete the Protocol Exam prior to submitting your application for licensure. * = Required Field
Renewal or Change of Level*
- Renewal
- Change of Level
EMS Provider License Type*
- Apprentice
- EMR
- EMT
- AEMT
- Paramedic
- NH EMT (Non NREMT)
LIN
Current National Registry of EMTs Number*
Current NH EMS License Number*
Legal Name*
First Middle Last Suffix
Date of Birth*
MM slash DD slash YYYY
Gender
- Male
- Female
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email*

Email Note: an email that is unique to you is required. Your EMS license will be emailed to this address. You will not receive a mailed hardcopy of your new license card.
Best Contact Phone Number*
Phone number type*
- Cell
- Home
- Work
Last four digits of social security number*
Are you affiliated with a NH licensed EMS Unit?*
- Yes
- No
By licensing as a non-affiliated EMS provider, you certify that you have no affiliations with any licensed EMS unit.*
- I agree
- I disagree
Affiliation Note: To be licensed as an EMS provider in the State of New Hampshire you must be affiliated with at least one NH licensed EMS unit. If you list a unit below that you are not already affiliated with, your application may be delayed until we can contact an authorized representative from the unit to approve your affiliation request. You can also have an authorized representative send an email directly to emslicensing@dos.nh.gov requesting and approving your affiliation.
Unit Affiliation*
Agency Head/Chief/Training Officer Name*
Agency Head/Chief/Training Officer Email address*
Upload current CPR card:*
Max. file size: 1 GB.
Upload Apprentice Provider Affiliation form*
Max. file size: 1 GB.
You can download a sample of this form here: https://www.nh.gov/safety/divisions/fstems/ems/documents/sampleapprentice.pdf
Please upload a copy of your NREMT Card*
Max. file size: 1 GB.
Upload other additional documentation
Drop files here or

Max. file size: 1 GB.
Please upload any additional documentation that may be need. This may include any additional information you would like to submit.
FOR INFORMATION PURPOSES ONLY: Applicant Status with Primary Unit: (check one)
- Full-time
- Part-time
- Call
- Volunteer
AFFIRMATION STATEMENT
By signing below, I certify the following

a. All information provided on this application is complete, truthful, and correct under the penalties of unsworn falsification pursuant to RSA 641:3.
b. I have not been convicted or found guilty of an offense pursuant to RSA 153-A:13 I, (for additional information refer to Section A2)
c. I agree to comply with RSA 153-A and Saf-C 5900
d. I understand any material falsification of information shall result in license denial, suspension, or revocation, in accordance with Saf-C 5922.03 or SafC 5922.05 and may be grounds for a misdemeanor conviction pursuant to RSA 641:3.
e. I have not been subject to limitation, suspension from, or under revocation or probation of the ability to practice in a health care occupation or voluntarily surrendered a health care license in any state or to any agency authorizing the right to work.

If you are uncertain if a past incident violates one or more of the acts or offenses prohibited in the above Certifying Statement, please attach to your application a detailed explanation including the current status of the act(s) or offense(s) and provide relevant documentation concerning any charge(s), disciplinary action(s) disposition(s) and outcome(s).
Signature*
Date signed*
MM slash DD slash YYYY