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The form collects registry number, personal identification details, mailing contact information, and includes sections for criminal conviction disclosure. It also requires employer certification, physician medical director skill competency attestation, and applicant affirmation. Guidance explains completion requirements and submission via email, with processing timelines and recertification office contact details.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/inactive-to-active-request-form-ems/375143/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/inactive-to-active-request-form-ems/375143.png","ImageObject",300,407,{"name":92,"@type":93},"kopisore","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-23",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of the Inactive to Active Request Form?","Question",{"text":112,"@type":113},"It provides the paperwork an EMS professional needs to request returning certification from inactive status to active status with the National Registry of EMTs.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What submissions are required to process the request?",{"text":117,"@type":113},"Complete all sections of the form, obtain required signatures, and email the completed form and documentation to the NREMT address provided.",{"name":119,"@type":110,"acceptedAnswer":120},"How is criminal history handled on the form?",{"text":121,"@type":113},"The form includes a Criminal Conviction Statement section asking whether you were convicted or subject to restrictions during the inactive period, and it requires official documentation if you answer yes.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},375143,1790692458,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24},962090880963,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","THE NATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS  \nInactive to Active Request Form  \nPlease Read Instructions  \nReg ist ry Num ber  \n\n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\nSo c i a l  \nSe c u rit y Num ber  \n\n|  |  |  |\n| --- | --- | --- |\n\n_ _  \n\n|  |  |\n| --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nLast  \nName  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nF i r s t Name  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nM i d . I n i t .  \nMa i l i n g Address  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nC it y  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nState  \n\n|  |  |\n| --- | --- |\n\nZ i  \nCod  \np e  \n\n|  |  |  |  |  |\n| --- | --- | --- | --- | --- |\n\n_  \n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\nE-m a i l  \n\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nPhone Num ber  \n\n|  |  |  |\n| --- | --- | --- |\n\n_    \n\n|  |  |  |\n| --- | --- | --- |\n\n\n|  |  |  |  |\n| --- | --- | --- | --- |\n\n\n| CRIMINAL CONVICTION STATEMENT |  |  |  |  |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n| YES\u003Cbr>YES | | NO\u003Cbr>NO |  | During your inactive period , were you convicted of a criminal conviction?\u003Cbr>During your inactive period , were you subject to limitation, suspension from, or under revocation or probation of your right to practice in a health care occupation or voluntarily surrendered a health care licensure in any state or to any agency authorizing the legal right to work?\u003Cbr>to either question, you must provide official documentation that fully describes the offense, current status case. |\n|  |  |  |  |  |\n|  |  |  |  |  |\n| If you answered “yes”and disposition of the |  |  |  |  |\n\n\n| EMPLOYER CERTIFICATION |  |\n| --- | --- |\n| I certify that the applicant named above is presently working /\u003Cbr>or will be employed upon obtaining active status, with our agency:\u003Cbr>Authorized Agent Signature Date\u003Cbr>Printed Name of Authorized Agent | Agency:  \u003Cbr>Address:   City:  State:   Zip Code:  \u003Cbr>Daytime Phone Number:   |\n\n\n| SKILL COMPETENCY VERIFICATION | Direct Obs. | Other |\n| --- | --- | --- |\n| 1. PATIENT ASSESSMENT / MANAGEMENT: Medical and Trauma Patients |  |  |\n| 2. VENTILATORY MANAGEMENT SKILLS / KNOWLEDGE: Adjuncts, Oxygen Delivery, Alternative Airways* Endotracheal Intubation*, Chest Decompression* / Cricothyrotomy* |  |  |\n| 3. CARDIAC ARREST MANAGEMENT: AED, Megacode & EKG Recognition / Set-Up*, Therapeutic Modalities* |  |  |\n| 4. HEMMORHAGE CONTROL & SPLINTING PROCEDURES |  |  |\n| 5. IV THERAPY & IO THERAPY*: Medication Administration* |  |  |\n| 6. SPINAL IMMOBILIZATION: Seated and Supine Patients |  |  |\n| 7. OB/GYNECOLOGICAL SKILLS / KNOWLEDGE |  |  |\n| 8. OTHER RELATED SKILLS / KNOWLEDGE: Radio Communications, Report Writing & Documentation |  |  |\n| As the Physician Medical Director of the above listed registrant, I do hereby affix my signature attesting the registrant has demonstrated sufficient competence to return to active status.\u003Cbr>*Physician Medical Director Signature (MD) Title Position Date Signed (Training Officer may sign for EMT level ONLY)\u003Cbr>(must be original signature) * If applicable to your level or area |  |  |\n\n\n| APPLICANT AFFIRMATION OF APPLICATION | Office Use Only |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| I hereby af","cbCaiusS91M6LtSW","https://ap.wps.com/l/cbCaiusS91M6LtSW","pdf",406823,"English","# Inactive to Active Request Form\n## Required applicant information\n## Criminal conviction statement\n## Employer certification\n## Skill competency verification\n## Applicant affirmation of application\n## Submission instructions and processing timeline","[{\"question\":\"What is the purpose of the Inactive to Active Request Form?\",\"answer\":\"It provides the paperwork an EMS professional needs to request returning certification from inactive status to active status with the National Registry of EMTs.\"},{\"question\":\"What submissions are required to process the request?\",\"answer\":\"Complete all sections of the form, obtain required signatures, and email the completed form and documentation to the NREMT address provided.\"},{\"question\":\"How is criminal history handled on the form?\",\"answer\":\"The form includes a Criminal Conviction Statement section asking whether you were convicted or subject to restrictions during the inactive period, and it requires official documentation if you answer yes.\"}]","Inactive to Active Request Form - EMS | PDF",1790207449]