Authority of the State / Illinois Department of Public Health Division of Emergency Medical Systems and Highway Safety / Date CENTRAL OFFICE / Illinois Illinois Department of Public Health Emergency Medical Services / /
Position
medical director for inactive status / Medical Director / Director / REMSC Signature / /
State of Illinois Illinois Department of Public Health Emergency Medical Services (EMS) Systems Inactive Request All areas must be completed or the application will be returned unapproved. Applicant Name ________________