DUPLICATE CARD REQUEST

This form is for requesting a duplicate/replacement Paramedic Accreditation, EMT Certification, or EMR Certification card.

There is a $25.00 fee for the replacement of card.

*American Express is not accepted.

First & Last Name:

Email Address:

Cell Phone Number:

Certificate/License #:

Payment:

A non-refundable duplicate card fee must be paid in order to process your request. Online requests can only be paid using a credit card and the card number will be encrypted for security purposes when submitted.

Duplicate Card Fee is $25.00. Please enter your credit card information below for payment.

Credit Card Number: (Will be encrypted when submitted) (Please use format with dashes)

Credit Card Expiration Date:

Dollar amount to be charged:

CVV2 (3 digits on back of card):

Name as it appears on card:

Phone number related to card: (Please use format with dashes)

By submitting this information, I hereby authorize YEMSA to charge my credit card in the amount noted above.

YES

Affirmation & Signature:

I hereby declare that my certification/accreditation card has been lost or stolen, and request that a duplicate card be issued. Furthermore, I certify that all information on this form, to the best of my knowledge is true and correct.

First Name

Last Name

Choose how to sign

Draw Type

Once all your information is received and verified, then your request will be processed within ten (10) business days.

Your feedback is valuable in improving our online application process. Do you have any questions or comments: