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 Branch Vocational, Business, OtherDid you graduate?* YES NO Degree in* CURRENT EMPLOYMENTCompany Job Title Employed from: MM slash DD slash YYYY Employed until: 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/ Guardian Date* 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. CAPTCHA Δ Contact Us Name* First Last Phone*Email* QuestionCAPTCHA Δ
