Paramedic Program Application

Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
NREMT Certification Number (If you are not NREMT, put N/A)*
Iowa Certification Number*
IA Certification Number
1. How many years of experience in EMS?*
2. Do you work full time?*
- Yes
- No
Where do you work?*
3. Are you currently on a fire / rescue department?*
- Yes
- No
If yes, which department?*
4. Have you attended any Advanced EMS certification (paramedic or AEMT) courses in the past?*
- Yes
- No
If yes, please write details:
5. Are you interested in starting the Paramedic Program August 2024?
- Yes
- No
Please list 2 personal references:
Person #1*
First Last
Position/company*
Phone number:*
Email*
Person #2*
First Last
Position/company:*
Phone number:*
Email*

Please list 2 personal references: