IOCI 17-149 11/16 Printed by Authority of the State of Illinois
State of Illinois
Illinois Department of Public Health
Emergency Medical Services (EMS) Systems
Renewal Notice/Child Support/Personal History Statement
ONLINE RENEWAL AND PAYMENT CAN BE MADE AT www.dph.illinois.gov.
The following statements MUST be completed.
❑
I am up-to-date with child support payments.
❑ I am more than 30 days delinquent in complying with a court-ordered child support order.
❑ I do not have to pay child support.
❑ I have NOT been convicted of a felony.
❑ I HAVE been convicted of a felony.
If you have been convicted of a felony, attach a statement, in your own words, of the circumstances surrounding the incident.
An additional fee and authorization for release of information must be submitted to IDPH to obtain a criminal history report
from the Illinois State Police or other law enforcement agency. The release form and fee schedule can be found at
www.dph.illinois.gov.
Birthdate _____________________ SS#___________________________ DL# ______________________________
Month Day Year
E-Mail _________________________________________________ Phone Number ___________________________
Under penalties of perjury, I declare that I have examined the application and all supporting documents submitted by me in
connection herewith, and to the best of my knowledge, they are true, correct and complete. Failure to so certify shall result in
the denial of the request for license renewal.
Signature ___________________________________________________________ Date _______________________
This request for information is only the first part of the renewal process. Renew online or return this completed form,
with the appropriate fee, to the address provided below. Money order or cashier’s check accepted. Do Not Send Cash.
Proof of your continuing education hours MUST be submitted to your EMS System Coordinator or Trauma Nurse Specialist
Course Coordinator (whichever applicable) for review and approval.
If you are an independent, go to dph.illinois.gov and complete the Independent Renewal and follow the instructions for mailing.
License renewal will not be processed until all information and payment are completed and received.
Return to:
Illinois Department of Public Health
Division of EMS and Highway Safety
Attention: Licensure Section
422 South Fifth Street, Third Floor
Springfield, Illinois 62701
Name/Address
_____________________________________________
Name
_____________________________________________
Address
_____________________________________________
City, State, ZIP
