(a) Any individual desiring to be licensed under this chapter shall submit an application in the format prescribed by the Division to the Division. The application shall contain the following information: - (i) Full name and address of legal residence;
- (ii) Age, height, weight, color of eyes and hair;
- (iii) Proof of current medical certification or license, if applicable;
- (iv) Category of license desired;
- (v) Whether the applicant has been convicted of a crime against a person, a felony, or an offense against morals, decency and family;
- (vi) Whether the applicant has been the subject of limitation, suspension, or termination of their right to practice in a health care occupation or voluntarily surrendered a health care certification or license in any state or to an agency authorizing the legal right to work;
- (vii) Social Security Number;
- (viii) If the applicant desires to affiliate with an ambulance service and function in an attendant capacity, the applicant will indicate such on the application and submit the Attendant Affiliation Fee of two dollars ($2.00) payable to the State of Wyoming. The fee shall only be required once per licensure period, regardless of the number of affiliations. The Division shall provide a separate affiliation form for use when a licensed individual desires to affiliate with more than one ambulance service or changes affiliation.
- (ix) Proof of current certification in American Heart Association BLS (Basic Life Support) for Healthcare Providers or equivalent; and
- (x) Proof of current certification in American Heart Association Advanced Cardiac Life Support if the applicant is applying for licensure at the IEMT or Paramedic level.
- (xi) Any other information the Division determines is necessary to establish the person's qualification for licensure.
(b) Any individual desiring to be licensed as an EMT shall complete and submit to a criminal history screening as directed by the Department. The criminal history screening must contain federal and state criminal information, Costs of all necessary background checks and fingerprinting are the sole responsibility of the applicant.
(c) The Division may contact agencies or entities including, but not limited to, other state agencies, law enforcement agencies, national provider databanks, and medical personnel to verify information in the application.