Community Paramedic Application

Personal Information

Full Legal Name *

Date Of Birth *

Address *

Address

City

State/Province

Zip/Postal

Country

Cell Phone *

Home Phone

Work Phone

Email Address *

Education

High School

Graduation Date

Other Education (vocational training, college, etc.)

School

Graduation Date

Degree/Certificate

EMS Education

School

Graduation Date

Instructor

National Registry #

State License #

BLS Expiration Date

Work History

Name of Employer

Dates of Employment

Position

Reason for Leaving

Name of Employer

Dates of Employment

Position

Reason for Leaving

Ems Related Certifications

Certification

Expiration Date

Certification

Expiration Date

Certification

Expiration Date

Have you ever been convicted of a misdemeanor, felony, DUI or DWI or do you have any charges pending? *

Yes

If yes, please attach a separate page giving a brief description of the incident. Include dates and penalties assessed.

Have you ever been subject to limitation, suspension, or termination of your right to practice in a healthcare occupation or voluntarily surrendered a healthcare licensure in any state or to an agency authorizing the legal right to work? *

Yes

If yes, please attach a separate page giving a brief description of the incident. Include dates and penalties assessed.

File Upload

Maximum file size: 20.97MB

Please go to https://www.patientnotebook.com/adaircountyambulancedistrict/payment to complete your online payment. The cost of the class is $300 at this time. Please Save your receipt and attach it here for proof of payment.

How did you hear about the Community Paramedic Program *

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Community Paramedic Application

Personal Information

Education

Other Education (vocational training, college, etc.)

EMS Education

Work History

Ems Related Certifications

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