EMT Basic Class Application APPLICANT INFORMATIONName* First Last Email* Phone*Address* Street Address Apartment/Unit # City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you ever been convicted of a felony? YES NO If yes, explainEDUCATIONHigh School* GED Diploma Didn't Graduate College/UniversityDid you graduate?* YES NO Degree in:MilitaryHonorable Discharge? YES NO BranchVocational, Business, OtherDid you graduate?* YES NO Degree in*CURRENT EMPLOYMENTCompanyJob TitleEmployed from: Date Format: MM slash DD slash YYYY Employed until: Date Format: MM slash DD slash YYYY 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/ GuardianDate* Date Format: MM slash DD slash YYYY 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. Contact Us Name* First Last Phone*Email* Who Would You Like To Contact?*Bill Grubb, President/CEO - Team LeadershipBecky Davis, Manager - Payroll/Benefits/UniformsCraig Gebo, Director - Client Services/MarketingChris Haney, Director - Operations & Employee SupportBrian Long, Director - Risk & Safety/Driving/OMHSKim Metevier, Director - Accounts Payable/Billing Dept.Doug Miles, VP of Administration - CQI/EPCR/State ReportingDave Miller, VP of Operations - Network/Radios/PagersJeff Siarto, Manager - System SupportSelect RecipientQuestion
