New Jersey Department of Health

Office of Emergency Medical Services

PO Box 360

Trenton, NJ 08625-0360

609-633-7777 609-633-7839 (Fax)	emt verification report
Provider Name

Telephone Number

Fax Number

Name of Person Requesting

Signature

Date

PLEASE PRINT OR TYPE!	FOR OEMS USE ONLY
Name of Provider	ID Number	Level of Provider	Status	Actions	Expiration	Initial Cert. Date

Verifying OEMS Staff

Date

EMS-10

JUL 12

EMS-10, EMT Verification Report

EMS-10, EMT, verification report, OEMS, emergency medical services

EWhite

2006-01-25

NJDOH