EMT Basic Class Application For Admission

APPLICANT INFORMATION

Name*

First Last

Email*

Phone*

Address*

Street Address Apartment/Unit # City State ZIP Code

Have you ever been convicted of a felony?

YES
NO

If yes, explain

EDUCATION

High School*

GED
Diploma
Didn't Graduate

College/University

Did you graduate?*

YES
NO

Degree in:

Military

Honorable Discharge?

YES
NO

Branch

Vocational, Business, Other

Did you graduate?*

YES
NO

Degree in*

CURRENT EMPLOYMENT

Company

Job Title

Employed from:

Employed until:

DISCLAIMER AND SIGNATURE*

Please select the checkbox to agree.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment in the EMT program, I understand that false or misleading information in my application or interview may result in my release. I give STAR EMS permission to compete a criminal background check for the program as outlined in the prerequisites for eligibility. If under the age of 18, you must have a signature form a Parent or Legal Guardian. If you are over the age of 18 this does not apply.

Signature*

Parent/ Guardian

Date*

Miles, Grubb & Associates LLC DBA Star EMS in an equal opportunity/affirmative action employer. All qualified applicants will be considered without regard to race, color, gender, religion, national origin, marital status, ancestry, citizenship, veteran status, or physical or mental disability.