Licence Relinquishment

Please complete this form if you wish to relinquish your British Columbia EMA Licence.

Licence NumberMissing or incorrect value

Last NameMissing or incorrect value

First Name(s) (full legal name)Missing or incorrect value

Email AddressMissing or incorrect value

By checking yes you verify that you no longer wish to be licensed as an EMA in BC and that you hereby relinquish your licence effective immediately

Missing or incorrect value

Personal information on this form is collected by the EMA Licensing Board under the authority of the Freedom of Information and Protection of Privacy Act Section 26(c) Emergency Health Services Act (section 6) and the Emergency Medical Assistant Regulation (sections 2, 3, 4, 9.2, 10 and 26). This information will be used to relinquish an EMA licence. If you have any questions about the collection of this information contact our office at PO Box 9625 Stn Prov Govt, Victoria B.C., V8W 9P1, phone 250 952-1211. This information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only in accordance with that Act.

HLTH 9736 Rev. 2023/01/23

Licence Relinquishment

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