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Upcoming start dates Paramedic: Now Enrolling!
February 11th, 2010

EMT-Basic: Now Enrolling!
January 11th, 2010

Student loans available!
Contact our admissions office for
more information.

480.898.0911
admissions@dcmedprep.com

Start your career today!
Submit your application for any of
our programs, or call or email us.

admissions@dcmedprep.com

Application

Please complete the form below, type in your initials and click submit when finished.

Personal Information

* = Required

Program	Paramedic EMT
Last Name*
First Name*
Street Address*
City*
State*
Zip Code
Home Phone*
Work Phone
Email Address
SSN

Education history

College
Degree Earned
Date (mm/yy)

College
Degree Earned
Date (mm/yy)

College
Degree Earned
Date (mm/yy)

EMT completed at:
Date (mm/yy)
Certification #
Expiration Date
Haz Mat completed at
Date(mm/yy)
CPR Card Expiration Date

EMS Employment

Are you currently employed by an EMS agency?
If yes, name of agency
Lenght of Employment?
Immediate Supervisor
Street Address
City
State
Zip Code

Do you have any physical or emotional disabilities that would keep you from performing the functions of a Paramedic?
Yes or No?
If yes, please explain

Have you ever been convicted of a felony?
Yes or No?
If yes, please explain

I fully understand that any significant misstatements in or omissions from this application constitute cause for dismissal from the Paramedic Program. All information submitted by me in this application is true to the best of my knowledge.

I hereby authorize and consent to the release of information regarding the training program by DC Med Prep if such release of information is done in good faith and without malice, and I hereby release from liability DC Med Prep and its representatives for so doing.

Please Initial*

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Application

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