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 FieldRenewal or Change of Level*RenewalChange of LevelEMS Provider License Type*ApprenticeEMREMTAEMTParamedicNH EMT (Non NREMT)LIN*Current National Registry of EMTs Number*Current NH EMS License Number*Legal Name* First Middle Last Suffix Last four digits of social security number*Best Contact Phone Number*Phone number type*CellHomeWorkDate of Birth* Date Format: MM slash DD slash YYYY GenderMaleFemaleMailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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. 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. Primary Unit Affiliation*Agency Head/Chief/Training Officer Name*Agency Head/Chief/Training Officer Email address* Upload current CPR card:*Upload Apprentice Provider Affiliation form*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*Upload other additional documentation Drop files here or 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-timePart-timeCallVolunteerAFFIRMATION STATEMENT“I have never been convicted of or found guilty of an offense pursuant to RSA 153-A:13, I (h) and I am in full compliance with RSA 153-A, and the rules adopted thereunder.”I AFFIRM AND AGREE TO THE ABOVE STATEMENT Pursuant to RSA 153-A*YESNO“I have never been convicted of or found guilty of an offense pursuant to RSA 153-A:13, I (h) and I am in full compliance with RSA 153-A, and the rules adopted thereunder.”I AFFIRM AND AGREE TO THE ABOVE STATEMENT Pursuant to RSA 153-A*YESNOSignature*Date signed* Date Format: MM slash DD slash YYYY