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