Fillable Printable Declaration of Identity Form

Declaration of Identity Form

DECLARATION OF IDENTITY

I, ____________________________________________________________________________

Printed Full Name of Declarant

do hereby certify and declare as follows:

1) I am the person I claim to be through presentation of valid identification

(driver's license, state ID card, passport, military ID) herewith to the Riverside

County Emergency Medical Services (EMS) Agency.

2) The certifications, licenses, accreditations, and training completion evidence I

present herewith to the Riverside County EMS Agency are:

a) issued to my person as identified in 1) above

b) unaltered

c) current and in good standing

3) The facts stated in this Declaration are true as of my personal knowledge.

_________________________________________ dated___________________, 20_______

Signature of Declarant

State of ________________________________________________

County of _______________________________________________

On _______________________ before me, ___________________________________________

Name and Title (Jane Doe, Notary Public)

personally appeared ______________________________________________________________

personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed

to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity and that by

his/her signature on the instrument the person executed the instrument.

WITNESS my hand and official seal.

_________________________________________________

Signature (Seal)