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The form specifies public disclosure of contact fields marked with a red asterisk, eligibility expectations for exam levels, CPR and ACLS expiration date entries, and additional credential reporting for coordinators. It also includes signature guidance, webinar confirmation for examiners, medical director and seminar attendance rules for approved agents, and submission routing to regional specialists or seminars.",{"@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":20,"@type":76,"position":81},"https://docshare.wps.com/document/exam/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/minnesota-approved-agentexaminer-application-instructions/369693/",{"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/minnesota-approved-agentexaminer-application-instructions/369693.png","ImageObject",300,407,{"name":92,"@type":93},"Đào","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-06","2026-09-23",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Which parts of the contact information are publicized on the EMSRB website?","Question",{"text":112,"@type":113},"Any contact information fields marked with a red asterisk in the contact information section will be listed on the EMSRB website.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What CPR/ACLS information must advanced examiners provide?",{"text":117,"@type":113},"Provide the current CPR and/or ACLS expiration dates. Advanced examiner applicants who are ACLS instructors must provide their ACLS instructor expiration date.",{"name":119,"@type":110,"acceptedAnswer":120},"How can an approved agent or examiner submit the application?",{"text":121,"@type":113},"Submit to the EMSRB regional specialist or bring it to the Approved Agent Seminar session you attend.","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},369693,1790184113,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":19,"category_name":20,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"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":129,"read_time":24,"preview_page_count":4},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","MINNESOTA APPROVED AGENT/EXAMINER APPLICATION  \nINSTRUCTIONS  \nProvide all information requested by this application form. Incomplete or illegible applications will be returned.  \n1. Contact Information  \n• Provide all requested contact information.  \n• Information in the contact information section of the application that contains a red asterisk,(i.e.; *Last Name) will be publicized on the EMSRB website.  \n2. Applicant Information  \n• Please place a check mark in the box for each position you are applying for.  \n• Provide your current EMSRB Certification Number.  \n• Provided current CPR and/or ACLS expiration dates (both if applicable).  \n• Advanced examiner applicants: (ACLS Instructors) please provide your current expiration date. Advanced examiner applicants: (non-ACLS Instructors) Only advanced examiners who are ACLS Instructors can facilitate testing at the cardiology stations. Both Non-ACLS Instructors and ACLS Instructors can facilitate all other areas of the advanced examination.  \n3. Region  \nPlease circle the regions in which you would like to be an examiner. If you are willing to travel to any region, please circle “All Regions”.  \n4. Credentials  \nProvide any additional credentials that may be beneficial for exam coordinators to be aware of.  \n5. Signature  \n• Carefully read the statement provided before signing and dating this application.  \n• Examiners: enter the date & time you viewed the required NREMT webinar“Best Practices for Psychomotor Exam Scoring”:  \n[https://www.nremt.org/nremt/about/resourcesWebinars.asp](https://www.nremt.org/nremt/about/resourcesWebinars.asp)  \n• Approved Agent Applications must be signed by a medical director.  \n• Approved Agent applicants must attend an EMSRB Approved Agent Seminar.  \n6. Submission  \nYou may submit your application to your EMSRB Regional Specialist or bring it to the Approved Agent Seminar session you attend.  \n2829 University Ave. S. E., Suite 310 Minneapolis, MN 55414-3222  \n(651) 201-2800 (800) 747-2011 FAX (651) 201-2812 TTY (800) 627-3529  \n[www.emsrb.state.mn.us](www.emsrb.state.mn.us)  \nApproved Agent / Examiner Application  \n* Contact information provided will be listed on the EMSRB website.  \n\n| *Last Name: |  |  | *First Name: |  |  | *Middle Initial: |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Street Address: |  |  | City: |  |  | State: | Zip: |\n| *Phone Number: |  | *Email Address: |  |  |  |  |  |\n| Applicant Information: All Information Required |  |  |  |  |  |  |  |\n| | Applying as EMT Psychomotor Exam Approved Agent |  |  | *EMSRB Certification \\#: |  |  |  |\n| | Applying as Basic Examiner |  |  | *CPR /ACLS Expire Date: |  |  |  |\n|  |  |  |  |  |  |  |  |\n| | Applying as Advanced Examiner |  |  | *ACLS Instructor Expire Date:\u003Cbr>(Advanced Examiners Only) |  |  |  |\n| Please circle which region(s) you are applying for: |  |  |  |  |  |  |  |\n| All Regions Central Metro Northeast Northwest |  |  |  |  |  |  |  |\n| Southeast South Central Southwest West Central |  |  |  |  |  |  |  |\n| Please identify other credentials that may be helpful: |  |  |  |  |  |  |  |\n| As an examiner in the State of Minnesota, I understand, I must be certified or licensed at or above the level being tested, perform the skill being evaluated, must be current in CPR, must have completed a board approved training course. I certify the information provided is true and correct to the best of my knowledge.\u003Cbr>The Date I Watched the Required Webinar: |  |  |  |  |  |  |  |\n| *Applicant’s Signature: |  |  |  |  | Date: |  |  |\n| Approved Agents Applicants Only\u003Cbr>I, as medical director for   (Ambulance Service or Education Program) to the best of my knowledge, verify this applicant is competent to act as an approved agent in the State of Minnesota during a Psychomotor Skills Examination.\u003Cbr>Medical Director   MN. Physician License \\#  \u003Cbr>(Print Name)\u003Cbr>Signature   Date  \u003Cbr>(Original Signature) |  |  |  |  |  |  |  |\n\n “To protect the public ’s health and safety","cbCailkSS4ntv7FA","https://ap.wps.com/l/cbCailkSS4ntv7FA","pdf",270829,"English","# Contact Information\n# Applicant Information\n# Region\n# Credentials\n# Signature\n# Submission","[{\"question\":\"Which parts of the contact information are publicized on the EMSRB website?\",\"answer\":\"Any contact information fields marked with a red asterisk in the contact information section will be listed on the EMSRB website.\"},{\"question\":\"What CPR/ACLS information must advanced examiners provide?\",\"answer\":\"Provide the current CPR and/or ACLS expiration dates. Advanced examiner applicants who are ACLS instructors must provide their ACLS instructor expiration date.\"},{\"question\":\"How can an approved agent or examiner submit the application?\",\"answer\":\"Submit to the EMSRB regional specialist or bring it to the Approved Agent Seminar session you attend.\"}]","Minnesota Approved Agent/Examiner Application - Instructions | PDF"]